A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station.
Which of the following interventions should the nurse implement?

Apply counterpressure during each contraction.

Administer a dose of terbutaline to the client.

Request the provider prescribe a pudendal nerve block.

Place the client in a warm bath.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Counterpressure is a nonpharmacologic pain management technique that involves applying firm, steady pressure to the sacral area during contractions. It is particularly effective for back pain during labor, which is often caused by the occiput of the fetus pressing against the maternal sacrum. This physical pressure helps to distract the brain from the pain signals and can help to realign the fetal head. It provides direct relief by counteracting the pressure from the fetus.

Choice B rationale

Terbutaline is a tocolytic medication that is used to relax the smooth muscles of the uterus and inhibit contractions. Administering this medication would halt the progression of labor, which is not the goal in this situation. The client is in the latent phase of labor, and the primary goal is to manage the pain while allowing the labor process to continue naturally. Therefore, terbutaline is contraindicated as it would interfere with the normal course of labor.

Choice C rationale

A pudendal nerve block is a form of regional anesthesia that anesthetizes the pudendal nerve, providing pain relief to the perineum, vulva, and vagina. It is typically administered in the second stage of labor just before delivery or for an episiotomy repair, as it is not effective for the pain associated with uterine contractions. The client is in the latent phase of labor and experiencing back pain, so a pudendal block would not be an appropriate intervention at this time.

Choice D rationale

While a warm bath can be a useful comfort measure during labor, it is not the most effective intervention for severe back pain specifically caused by the fetal position. Counterpressure provides targeted, direct pressure to the source of the pain, offering more immediate and substantial relief. A warm bath may provide general relaxation and distraction, but it does not address the underlying mechanical cause of the pain as effectively as counterpressure.

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Correct Answer is D

Explanation

Choice A rationale

Dark spots or floaters in vision are not a typical post-operative finding for cataract removal. They are more commonly associated with retinal detachment, which is a rare but serious complication. The client should be instructed to report this to the provider immediately.

Choice B rationale

Bruising of the eyelids is not a normal or expected outcome after cataract surgery. The procedure is typically performed with a small incision and does not cause significant trauma to the surrounding tissues, making bruising an uncommon occurrence.

Choice C rationale

Cataract surgery is almost always performed using a local anesthetic, not general anesthesia. A local anesthetic is administered to numb the eye and surrounding area, allowing the client to remain awake and aware during the procedure while feeling no pain.

Choice D rationale

The fundamental principle of cataract surgery is the removal of the clouded, opaque lens and its replacement with a clear, artificial intraocular lens (IOL). This is the definitive treatment for cataracts, restoring visual clarity and function to the eye. *.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Why Safety Comes First

The client presents with multiple red flags for physical abuse and neglect, including bruises in various stages of healing, a fracture, and concerning behavior around the adult child.
Ensuring the client is in a safe environment is the top priority to prevent further harm and initiate protective interventions.

Why Nutritional Status Is Next

The client reports limited food availability and has a low BMI (18.3), suggesting possible malnutrition.
Addressing nutritional needs is essential for recovery and overall well-being, especially in older adults who are vulnerable to rapid health decline.

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A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station. Which of the following interventions should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

Correct Answer is D

Explanation

The nurse should first address the client’s dropdown followed by the client’s dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

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A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station.
Which of the following interventions should the nurse implement?