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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct Answer is D
Explanation
Choice A reason
Re-evaluate the client for an ET cuff leak is not appropriate. While an ET cuff leak could contribute to respiratory distress, the immediate concern is the high-pressure alarm, which indicates increased resistance to airflow. The nurse should address the alarm first and then assess for other potential causes, including an ET cuff leak.
Choice B reason:
Option B: Assess for disconnected tubing is not appropriate. A disconnected tubing is also a potential cause of the high-pressure alarm. However, before checking for disconnected tubing, the nurse should first deliver manual breaths with a resuscitation bag to provide the client with adequate ventilation.
Choice C reason:
Decrease the ventilator flow rate is not appropriate. Decreasing the ventilator flow rate might not be the appropriate action in this situation, as the high-pressure alarm indicates increased resistance, which might require increased flow to overcome. Additionally, the nurse should not delay taking immediate action by adjusting ventilator settings without knowing the specific cause of the high-pressure alarm.
Choice D reason:
When the high-pressure alarm is beeping, and the client is experiencing respiratory distress, it indicates that there is an increased resistance to airflow within the ventilator circuit or the client's airway. This can be a life-threatening situation, and immediate action is required.
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