A nurse is caring for a client who is in labor.
Which of the following nursing actions reflects application of the gate control theory of pain?
Massage the client’s back.
Administer prescribed analgesic medication.
Turn the client onto her left side.
Encourage the client to rest between contractions.
The Correct Answer is A
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering oxytocin infusion is usually done to stimulate uterine contractions and prevent postpartum hemorrhage. However, it’s not the first action to take when the client’s blood pressure is low.
Choice B rationale
Evaluating the firmness of the uterus is crucial in this situation. A soft or “boggy” uterus could indicate uterine atony, a condition that can lead to serious postpartum hemorrhage. This could be the cause of the client’s low blood pressure.
Choice C rationale
Initiating oxygen therapy by non-rebreather mask can help increase the client’s oxygen saturation levels, but it doesn’t address the underlying cause of the low blood pressure.
Choice D rationale
Obtaining a type and crossmatch is important if the client needs a blood transfusion. However, it’s not the first action to take. The nurse should first assess for possible causes of the low blood pressure.
Correct Answer is B
Explanation
Choice A rationale
While excessive fatigue and headache can occur in pregnancy, they are not typically signs of labor.
Choice B rationale
A sudden gush of clear fluid from the vagina, also known as rupture of membranes, is a sign that labor may be starting.
Choice C rationale
Sharp, right-sided abdominal pain is not a typical sign of labor. It could indicate other issues such as appendicitis.
Choice D rationale
An increased pulse rate and upper abdominal pain are not typical signs of labor.
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