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 ["D","E"]
Explanation
Deep tendon reflexes (DTR):At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.
Heart rate:At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.
Other findings:
Urine output 40 mL in the last hour:Adequate urine output (at least 30 mL/hr) is a sign of improved renal perfusion and hydration status. Earlier, the client had only 20 mL in the last hour, which was concerning.
Temperature 38.3°C (101°F):This indicates a fever, which is not a sign of improvement.
Blood pressure 146/96 mm Hg:Although this is better than a severely hypertensive reading, it is still elevated.
Correct Answer is B
Explanation
The correct answer is B. Productive cough with thick mucus. Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis bacteria. It causes severe coughing spells that can interfere with breathing and produce a characteristic whooping sound when inhaling. The cough may also be accompanied by thick mucus that can be difficult to clear. Therefore, a nurse should expect to see a productive cough with thick mucus as a manifestation of pertussis in a child. The other options are not typical manifestations of pertussis, but rather of other conditions. A beefy, red tongue may indicate vitamin B12 deficiency or pernicious anemia. Facial erythema may indicate fever, allergy, or inflammation. Peeling of the hands and feet may indicate Kawasaki disease, a rare inflammatory disorder that affects the blood vessels.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.