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.
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Related Questions
Correct Answer is C
Explanation
A. Using a plastic cover on the crib mattress is not recommended because it can increase the risk of suffocation or overheating. Crib mattresses should be kept clean, but protective covers are not recommended for safety.
B. Placing a foam-wedge cushion under the newborn during naps is unsafe and increases the risk of Sudden Infant Death Syndrome (SIDS). Newborns should be placed on a firm, flat mattress for all sleep periods.
C. Ensuring that the mattress fits securely against the sides of the crib is crucial for preventing suffocation hazards. A snug fit between the mattress and crib sides prevents entrapment and ensures the baby’s safety while sleeping.
D. Placing bumper pads between the mattress and the rails of the crib is considered dangerous as they can pose suffocation and strangulation risks. Bumper pads are not recommended due to these safety hazards.
Correct Answer is B
Explanation
A. Placing a rolled blanket behind the newborn’s neck is unsafe and can cause improper positioning in the car seat. The newborn should be positioned properly according to the car seat manufacturer's instructions to ensure safety during travel.
B. The car seat should be positioned at a 45° angle to keep the newborn’s airway open and prevent slumping. This angle supports proper head and neck alignment, which is essential for the baby’s safety and comfort during travel.
C. The retainer clip should be positioned at the level of the newborn’s armpits, not the umbilicus. Proper placement of the retainer clip ensures that the harness is secure and correctly positioned over the baby’s shoulders.
D. Newborns should be placed in a rear-facing position in the car seat for optimal safety. Forward-facing car seats are used later, but infants should always be in a rear-facing car seat until they meet the age, weight, and height requirements for transitioning.
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