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."

Answer and Explanation

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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Correct Answer is A

Explanation

A. Group B Streptococcus (GBS) status is typically re-evaluated at around 36 weeks of gestation to determine if prophylactic antibiotics are needed during labor to prevent transmission to the baby.
B. A positive GBS test does not automatically indicate a cesarean birth. Intravenous antibiotics during labor are generally used to prevent transmission of GBS to the newborn.
C. GBS infection can cause serious complications in newborns, but hearing loss is not a typical outcome. The primary concerns are sepsis, pneumonia, and meningitis.
D. Antibiotics for GBS are given during labor, not the last two weeks of pregnancy. The treatment aims to reduce the risk of GBS transmission to the baby during delivery.

A. Administer the medication into the deltoid muscle. B. Administer the medication with a 25-gauge needle. C. Administer the medication 12 hr after birth. D. Check the mother's Rh factor prior to administration. E. None F. None

Correct Answer is C

Explanation

A. The deltoid muscle is not recommended for newborns; the vastus lateralis is the preferred site for intramuscular injections.
B. A 25-gauge needle is an appropriate size for newborn injections, but needle choice alone is not the priority action for this specific medication administration.
C. Phytonadione (Vitamin K) is typically administered within the first 6 to 12 hours after birth, allowing time for initial stabilization and bonding before injection, while still preventing vitamin K deficiency bleeding.
D. The mother’s Rh factor is unrelated to vitamin K administration; it is only assessed when considering the need for Rho(D) immune globulin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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