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

Choice A rationale:

This statement implies that the nurse attempted the dressing change but was unsuccessful. However, the information about the dressing not being soiled is irrelevant to the incident report. The key issue is the omission of the prescribed procedure.

Choice B rationale:

This statement acknowledges the omission but lacks specificity. It does not state the nature of the omission or the potential consequences, making it less informative for future prevention strategies.

Choice C rationale:

This statement clearly and concisely states the situation, indicating that the prescribed dressing change was omitted. It provides essential information for understanding what happened, allowing for appropriate investigation and preventive measures.

Choice D rationale:

This statement confirms the completion of the incident report but does not provide details about the incident itself. Without specific information about the omission, this statement is insufficient for understanding the nature of the error and implementing preventive actions.

A. "I can expect my eyelids to be bruised after this procedure.” B. "I will see dark spots in my vision after this procedure.” C. "I will receive general anesthesia for this procedure.” D. "I know the provider will replace the lens in my eyes during this procedure.”

Correct Answer is D

Explanation

Choice A rationale:

The statement, "I can expect my eyelids to be bruised after this procedure," indicates an understanding of the common side effects of cataract removal surgery. Bruising around the eyes is a common occurrence due to the manipulation of tissues during the procedure.

Choice B rationale:

The statement, "I will see dark spots in my vision after this procedure," is incorrect. Dark spots in vision are not a normal or expected outcome of cataract removal surgery. This statement shows a misunderstanding of the procedure.

Choice C rationale:

The statement, "I will receive general anesthesia for this procedure," is incorrect. While anesthesia is administered during the procedure, specifying the type of anesthesia is not crucial for the client's understanding of the surgery itself. The focus should be on the procedure details rather than the type of anesthesia.

Choice D rationale:

The statement, "I know the provider will replace the lens in my eyes during this procedure," indicates a clear understanding of the cataract removal procedure. The main goal of cataract surgery is to remove the cloudy lens and replace it with a clear artificial lens, improving the patient's vision. This statement demonstrates the client's comprehension of the surgery process.

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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 creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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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?