A nurse is caring for a client who is in the early stages of labor and requests nonpharmacological interventions for pain. Which of the following actions should the nurse take?

Encourage the client to void often.

Assist the client in remaining awake between contractions.

Minimize the client's position changes.

Limit the amount of time the support person remains in the room.

Answer and Explanation

The Correct Answer is A

A)   Correct - Encouraging the client to void often is important, as a full bladder can increase discomfort and interfere with labor progress.
B)   Incorrect- Remaining awake between contractions might not directly address pain management strategies.
C)   Incorrect- Position changes can help with pain management, so minimizing them would not be appropriate.
D)   Incorrect- The presence of a support person is often encouraged during labor, and there is no need to limit their time in the room.

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Correct Answer is C

Explanation

A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.

B) Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C) Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D) Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.

A. Instruct the client that oxytocin is administered during the procedure. B. Inform the client that this procedure assists in indicating Down syndrome. C. Assist the client to a lateral tilt position prior to the procedure. D. Ensure the client has been NPO for 6 hr prior to the procedure.

Correct Answer is C

Explanation

A) Incorrect- Oxytocin is not typically administered during a nonstress test.

B) Incorrect- A nonstress test is used to assess fetal well-being and does not indicate Down syndrome.
C) Correct - A lateral tilt position (usually left lateral tilt) is recommended during a nonstress test to prevent compression of the vena cava and maintain proper blood flow to the uterus, which can optimize fetal heart rate monitoring.
D) Incorrect- NPO status is not typically required for a nonstress test. Nonstress tests are non-invasive and do not involve fasting.

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A nurse is caring for a client who is in the early stages of labor and requests nonpharmacological interventions for pain. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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