A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?
"Assist her to breathe in deeply at the beginning of each contraction."
"Apply steady pressure with this tennis ball to her sacral area."
"Gently stroke her abdomen during contractions."
"Help her to focus on an object in the room."
The Correct Answer is C
The correct answer is C. Effleurage is a type of massage that involves gently stroking or rubbing the abdomen during contractions to provide comfort and distraction. It can also stimulate endorphin release and reduce pain perception. Breathing deeply at the beginning of each contraction is a relaxation technique, not effleurage. Applying pressure to the sacral area with a tennis ball is a counterpressure technique, not effleurage. Focusing on an object in the room is a focal point technique, not effleurage.
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Related Questions
Correct Answer is A
Explanation
The correct answer is A.
Wipe any excess medication from the inner canthus outward. Bacitracin ophthalmic ointment is an antibiotic that treats bacterial infections of the eye.
The nurse should apply a thin layer of ointment along the lower eyelid margin and wipe any excess medication from the inner canthus (the corner of the eye near the nose) outward with a sterile gauze pad or tissue to prevent clogging of tear ducts and spreading of infection.
Correct Answer is C
Explanation
Choice A reason:
Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.
Choice B reason:
Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag
Choice C reason:
Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.
Choice D reason
Infuse 500 ml lactated Ringer's IV.This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.
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