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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- A. Adjust the crutches for comfort as needed. This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidance.
- B. Use a three-point gait. This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.
- C. Wear leather-soled shoes. This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.
- D. Advance the affected leg first when walking upstairs. This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.
Correct Answer is B
Explanation
You have the right to change your mind about this procedure at any time.
Rationale:
- A. "Perhaps you think the ECT is dangerous, but I've seen it have good results." This response is dismissive of the client's concerns and implies that the nurse knows better than the client.
- B. "You have the right to change your mind about this procedure at any time." This response respects the client's autonomy and informs them of their rights.
- C. "Everyone gets a little nervous about this procedure as the time for it approaches." This response minimizes the client's feelings and assumes that they are experiencing normal anxiety.
- D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you." This response shifts the responsibility to the doctor and does not address the client's fears.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.