A nurse is contributing to the plan of care for a client who is in early labor and reports low-back pain during contractions. Which of the following interventions should the nurse include in the plan?
"Assist the client's partner to apply counterpressure to the sacrum."
"Teach the client to hold their breath during contractions."
"Maintain the client on bed rest until active labor begins."
"Insert an indwelling urinary catheter."
The Correct Answer is A
A. Counterpressure applied to the sacrum is effective for relieving low-back pain during labor. This technique can help alleviate discomfort associated with contractions and provide comfort to the laboring client.
B. Holding the breath during contractions is not recommended as it can decrease oxygen flow to the mother and baby. Breathing techniques that focus on relaxation and proper oxygenation are preferred.
C. Bed rest is not necessary for a client in early labor and can be counterproductive. Allowing the client to move and find comfortable positions is more beneficial during early labor.
D. An indwelling urinary catheter is not required in early labor unless there is a specific medical reason. Routine catheterization is not a standard part of early labor management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- Potential Condition: Endometritis. The symptoms of malaise, chills, decreased appetite, elevated temperature, tachycardia, a boggy and tender uterus, and foul-smelling lochia are indicative of a postpartum infection, such as endometritis.
- Actions to Take:
- Monitor the lochia amount and odor: This will help assess the presence of infection and the effectiveness of treatment.
- Assist with the administration of prescribed antibiotics: Antibiotics are the primary treatment for endometritis.
- Parameters to Monitor:
- Temperature: Monitoring for fever can help assess the response to treatment and indicate if the infection is resolving or worsening.
- Heart rate: Tachycardia may be a sign of infection or other complications, so it's important to monitor changes in heart rate.
Correct Answer is C
Explanation
A. Fever is not a common adverse effect of epidural anesthesia. Fever is more commonly associated with infection or other causes and would require further investigation but is not directly linked to the epidural itself.
B. Tachypnea is not an expected adverse effect of epidural anesthesia. It may be a sign of anxiety, pain, or respiratory complications, but it is not typically caused by the epidural.
C. Tachycardia can be an adverse effect of epidural anesthesia. It may occur as a compensatory mechanism due to hypotension, which is a known side effect of epidural anesthesia. When blood pressure drops, the heart rate may increase to maintain cardiac output.
D. Hypertension is generally not associated with epidural anesthesia. Hypotension is more common due to the vasodilatory effects caused by sympathetic nerve blockade, rather than an increase in blood pressure.
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