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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Correct Answer is D
Explanation
Answer: D. I will make sure that I can fit one finger between the mattress and the side of my newborn's crib.
Rationale: The parent should make sure that the mattress fits snugly in the crib and that there are no gaps between the mattress and the side of the crib that could trap the newborn's head or body. This reduces the risk of suffocation or entrapment. The other statements by the parent are incorrect and unsafe practices that could harm the newborn.
Correct Answer is D
Explanation
The correct answer is D. Compare bilateral pedal pulses.
Rationale: The nurse should compare bilateral pedal pulses to assess for adequate circulation and perfusion to the lower extremities. Buck's traction is a type of skin traction that is widely used for broken femurs and hips, as well as fractures in the socket portion of the "ball-and-socket" hip joint (acetabular fractures). It uses splints, bandages, and adhesive tapes to position a limb near the fracture, then weights and pulleys are attached and pressure is applied. The nurse should not remove the weights for 20 min for the client's report of severe pain, as this would disrupt the alignment and traction of the fracture .
The nurse should not position the knot of the rope at the top of the pulley, as this would interfere with the smooth movement of the rope and reduce the effectiveness of traction. The nurse should not apply 6.8 kg (15 lb) of weight for use in traction, as this would exceed the recommended weight limit for skin traction and could cause skin damage or nerve injury. The weight should not exceed 4.5 kilograms at any point.
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