A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain.
Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.)
Perform Leopold maneuvers.
Apply counterpressure to the sacral area
Ambulate the client in the hallway
Administer 70-90% nitrous oxide mixed with oxygen
Correct Answer : B,C,D,E
Applying counterpressure to the sacral area can help alleviate back pain during labor.
Ambulating the client in the hallway can help with pain management and facilitate labor progress.
Administering nitrous oxide mixed with oxygen can provide pain relief during labor.
Having the client sit upright can help with pain management and facilitate labor progress.
Choice A is incorrect because performing Leopold maneuvers is a technique used to assess fetal position and presentation and is not a pain management technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A nurse assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation should indicate the need for further diagnostic testing if there are no late decelerations noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
Choice A is incorrect because an increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal result.
Choice B is incorrect because irregular contractions of 10 to 20 seconds in duration that are not felt by the client do not indicate the need for further diagnostic testing.
Choice D is incorrect because three fetal movements perceived by the client in a 20-min testing period do not indicate the need for further diagnostic testing.
Correct Answer is C
Explanation
The Babinski reflex, also known as the plantar reflex, is a normal reflex in infants
that occurs when the sole of the foot is stroked from heel to toe.
In response to this stimulus, the big toe moves upward or toward the top surface of the foot and the other toes fan out.
Choice A is not an answer because flexion of the forearm is not a response to stimulation of the foot.
Choice B is not an answer because downward curl of the toes is not a response
to stimulation of the foot.
Choice D is not an answer because extension of the leg is not a response to
stimulation of the foot.
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