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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Ticks should not be removed by squeezing the body with tweezers, as this can cause the tick to regurgitate its stomach contents into the bloodstream, increasing the risk of infection transmission. The proper technique involves using fine-tipped tweezers to grasp the tick as close to the skin's surface as possible and pulling upward with steady pressure.

Choice B rationale

Testing for Lyme disease is not recommended immediately after a tick bite because the antibodies may not be detectable yet. The incubation period for the bacteria is several weeks. It is recommended to watch for symptoms and seek testing only if the characteristic bull's-eye rash or other symptoms develop, which typically occurs 3 to 30 days post-bite.

Choice C rationale

Using a product with DEET (N,N-diethyl-meta-toluamide) is a highly effective measure for preventing tick bites. DEET acts as a repellent that deters ticks and other insects from landing on the skin or clothing. It is a proven preventative strategy that significantly reduces the risk of contracting Lyme disease when walking in wooded or grassy areas.

Choice D rationale

Symptoms of Lyme disease, such as the characteristic erythema migrans (bull's-eye rash), typically appear within 3 to 30 days after being bitten by an infected tick. They do not appear within 2 days. The incubation period is a crucial factor in monitoring for the disease and seeking timely medical care if symptoms arise. .

A. The provider will choose a client's health care surrogate. B. The client can resume control of health care after a temporary loss of competency. C. A health care surrogate must be a family member. D. The provider can go against the client's wishes regarding advance directives.

Correct Answer is B

Explanation

Choice A rationale

A healthcare surrogate, or proxy, is a person designated by the patient themselves through a legal document called a durable power of attorney for healthcare. The provider's role is to provide medical care, not to make legal decisions for the patient. The patient retains the autonomy to choose who will make decisions for them when they are unable to do so. This is a fundamental principle of patient self-determination and legal rights.

Choice B rationale

A patient's competency can fluctuate. In situations of temporary incapacity, such as during a surgical procedure with anesthesia or a period of severe illness, a health care surrogate may make decisions. However, once the patient regains competency and is able to make informed decisions for themselves, they automatically resume control of their health care. This is a core tenet of patient autonomy and the purpose of advance directives.

Choice C rationale

A healthcare surrogate does not have to be a family member. The person designated by the patient can be a friend, a partner, or any trusted individual. The only requirement is that the surrogate is an adult who is willing and able to make healthcare decisions on the patient's behalf. It is a legal designation, not a familial one, that is based on the patient's trust and personal wishes.

Choice D rationale

A provider is legally and ethically obligated to follow a patient's wishes as outlined in their advance directives, as long as those wishes are within the bounds of standard medical practice and are not medically futile. To go against a patient's documented wishes would be a violation of patient autonomy and a breach of the legal protections afforded by advance directives.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program?

Correct Answer is C

Explanation

A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has schizophrenia. The client states, "The voices in my head are driving me crazy.”. Which of the following Questions should the nurse ask?

A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?

A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

A nurse is caring for a group of clients and identifying what tasks she can delegate to an assistive personnel (AP). Which of the following tasks should the nurse delegate to an AP?

A nurse is assessing a client who is receiving enteral feedings via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings.

A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

A client presents to the clinic for a postoperative follow-up following surgical repair of a fractured radius. The client reports their adult child prepares two meals a day for them to eat. The client's weight is 55.9 kg (123 Ib) and height is 175 cm (69 in). What is the client's BMI?

A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?

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?