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 A
Explanation
A. A respiratory rate of 10/min indicates magnesium sulfate toxicity, which can cause respiratory depression. Close monitoring of respiratory rate is essential to identify and manage potential toxicity.
B. Urine output of 40 mL/hr is not an immediate sign of toxicity but requires monitoring. Decreased urine output can be a sign of complications, but it is not the primary indicator of magnesium sulfate toxicity.
C. Nausea is a common side effect of magnesium sulfate but not necessarily indicative of toxicity. More severe symptoms like respiratory depression are critical for diagnosing toxicity.
D. Facial flushing is a common, mild side effect of magnesium sulfate and not a sign of toxicity. Monitoring for more severe symptoms is essential to assess for toxicity.
Correct Answer is C
Explanation
A. Placing the baby in the bassinet by the bed when using the bathroom does not ensure the baby’s safety. It is important to use the bassinet only as a safe place for the baby, and the baby should not be left unattended or in potentially unsecured areas.
B. Carrying the baby in your arms while walking in the hallway does not prevent abduction and can be risky if you are not vigilant. It is safer to use secure methods for ensuring the baby's safety while moving through the hospital.
C. Ensuring that anyone caring for or transporting your baby is wearing an identification badge is a crucial safety measure. Identification badges help verify that only authorized personnel handle the baby, which helps prevent abductions.
D. If the baby’s identification band slips off, it should be reported immediately to hospital staff rather than being placed in a drawer. The identification band is essential for tracking and ensuring the baby’s safety, so it must be addressed properly to prevent confusion or security issues.
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