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?

Administer a dose of terbutaline to the client.

Place the client in a warm bath.

Apply counterpressure during each contraction.

Request the provider prescribe a pudendal nerve block.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Administering terbutaline is used to stop or slow down preterm labor contractions. In the given scenario, the client is in the latent phase of labor and is experiencing severe back pain. Terbutaline is not indicated for back pain during labor.

Choice B rationale:

Placing the client in a warm bath can provide comfort and relaxation, but it may not specifically alleviate back pain during labor. Additionally, warm baths are more commonly used for pain relief in early labor or during the active phase, not specifically for back pain.

Choice C rationale:

Applying counterpressure during each contraction is an appropriate intervention for relieving back pain during labor. Back pain is a common discomfort experienced by many women during labor, and counterpressure, often applied by a support person or nurse, can help alleviate the discomfort. It is a non-pharmacological method that can be effective in managing pain during labor.

Choice D rationale:

Requesting the provider prescribe a pudendal nerve block is not the first-line intervention for back pain during labor. Pudendal nerve blocks are used for pain relief during the second stage of labor (during delivery) and are typically administered by the provider if needed. It is not the appropriate intervention for back pain in the latent phase of labor.

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Correct Answer is C

Explanation

- A is incorrect because it is an example of self-disclosure, not altruism. Self-disclosure is sharing personal information or feelings with others.

- B is incorrect because it is an example of jealousy, not altruism. Jealousy is feeling threatened or resentful by someone else's success or happiness.

- C is correct because it is an example of altruism, which is helping others without expecting anything in return. Altruism can enhance self-esteem and coping skills for clients who have breast cancer.

- D is incorrect because it is an example of trust, not altruism. Trust is believing that someone is reliable and honest.

A. Apply topical calamine lotion. B. Encourage oral fluids. C. Administer acetaminophen as an antipyretic D. Initiate transmission-based precautions

Correct Answer is D

Explanation

Initiate transmission-based precautions.

Rationale:

B- Encouraging oral fluids is an important intervention for a child who has a fever, as it helps prevent dehydration and electrolyte imbalance. However, it is not the priority intervention, as it does not address the risk of infection transmission to other clients or staff.
A - Applying topical calamine lotion may help soothe the itching and discomfort caused by the vesicles, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
C - Administering acetaminophen as an antipyretic may help reduce the fever and provide symptomatic relief for the child, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
D - Initiating transmission-based precautions is the priority intervention, as it protects other clients and staff from exposure to the infectious agent that causes the vesicles and fever. The nurse should wear gloves, gown, mask, and eye protection when caring for the child, and place them in a private room or cohort them with other clients who have similar symptoms.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?

Correct Answer is C

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A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

Correct Answer is D

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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?