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 C
Explanation
Choice A rationale:
Activating the fire alarm system is the second action the nurse should take after rescuing the individuals in the area.
Choice B rationale:
Obtaining and using a fire extinguisher should only be attempted by personnel trained to do so. Using a fire extinguisher incorrectly can escalate the fire or cause harm to individuals in the vicinity. The priority is to evacuate and let trained personnel handle the fire.
Choice C rationale:
Evacuating clients from the area is an essential and immediate step. Evacuation ensures the safety of everyone in the area, preventing potential harm due to smoke inhalation or fire spread.
Choice D rationale:
Closing the doors and windows on the unit can help contain the fire and prevent its spread. However, this action should be taken after activating the fire alarm system and initiating the evacuation process. Closing doors and windows can buy some time and limit the fire's oxygen supply, but it should not delay the evacuation procedure.
Correct Answer is A
Explanation
- A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.
- B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.
- C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.
- D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.
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