A nurse is contributing to the plan of care for a client who is in the third trimester and reports difficulty sleeping. Which of the following statements should the nurse include?

"Drinking warm tea before bed can be helpful.”

"Doing relaxation exercises before bed can be helpful.”

"Sleeping on your right side can be helpful.”

"Soaking in a hot tub for 60 minutes can be helpful.”

Answer and Explanation

The Correct Answer is B

Choice A reason:

The nurse should not recommend drinking warm tea before bed for a pregnant client. Certain herbal teas might not be safe during pregnancy, and caffeine-containing teas should be limited due to their potential effects on the fetus. Therefore, it is best to avoid suggesting this option to the client.

Choice B reason:

This is the correct choice as relaxation exercises can be beneficial for pregnant clients who are experiencing difficulty sleeping. These exercises can help reduce stress, promote relaxation, and improve sleep quality without any adverse effects on the client or the baby.

Choice C reason:

The nurse should avoid recommending that the client sleep on their right side. While the left side is generally recommended during pregnancy to improve blood flow to the placenta and baby, sleeping on the right side is not harmful either. However, it is better to provide the most suitable option for promoting sleep, which is relaxation exercises as mentioned in Choice B.

Choice D reason:

Soaking in a hot tub for 60 minutes is not advisable during pregnancy. Prolonged exposure to high temperatures, such as in hot tubs or saunas, can raise the body's core temperature, potentially causing harm to the developing fetus. Pregnant individuals should avoid hot tubs to prevent overheating.

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Correct Answer is B

Explanation

Choice A reason:

Obtaining vital signs is essential in assessing the child's overall condition, but it is not the first action the nurse should take in this situation. The priority is to address the immediate concern of difficulty breathing.

Choice B reason:

Stopping the IV infusion is the most critical action the nurse should take first. Difficulty breathing can be a sign of a severe allergic reaction, and if it is related to the IV cefuroxime, stopping the infusion will prevent further administration of the medication and possibly worsening the reaction.

Choice C reason:

Administering epinephrine IM is not the first-line action in this scenario. Epinephrine is used in severe anaphylactic reactions, but it should not be given without a proper evaluation of the situation and a clear indication for its use.

Choice D reason:

Monitoring intake and output is an important nursing intervention, but it is not the priority when the child is experiencing difficulty breathing. Addressing the respiratory distress should be the initial focus to ensure the child's safety and well-being.

A. Visual analog scale. B. FACES. C. Word-graphic. D. Numeric.

Correct Answer is B

Explanation

Choice A reason:

The Visual Analog Scale (VAS) is a pain rating scale that involves a straight line with one end representing "no pain” and the other end representing "worst pain imaginable.” The individual marks a point on the line to indicate their pain level. This scale may not be suitable for a 3-year-old child as it requires a certain level of cognitive and numerical understanding to make a meaningful assessment, which a young child may not possess.

Choice B reason:

The FACES pain rating scale is a visual tool that uses a series of facial expressions ranging from smiling to crying to help individuals, especially children, express their pain level. A 3-year-old child can easily point to the facial expression that best matches their pain experience, making it a suitable choice for this age group.

Choice C reason:

The Word-Graphic Scale is a pain rating scale that combines verbal descriptors with a visual representation of the pain intensity. It may include words like "no pain,” "mild pain,” "moderate pain,” and "severe pain” along with corresponding symbols. While it can be used with children, a 3-year-old might have difficulty grasping the abstract nature of the scale and correlating words with pain levels.

Choice D reason:

The Numeric Rating Scale (NRS) requires the individual to rate their pain level on a scale from 0 to 10, with 0 being "no pain” and 10 being "worst pain.” Similar to the Visual Analog Scale, this scale might not be suitable for a 3-year-old child who may not fully understand abstract numerical concepts.

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A nurse is contributing to the plan of care for a client who is in the third trimester and reports difficulty sleeping. Which of the following statements should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a child who is receiving IV cefuroxime when the child begins to have difficulty breathing. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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