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 C
Explanation
The correct answer is C.
Check the child for oral injuries. The rationale is that during a tonic-clonic seizure, the child may bite their tongue, cheek or lips and cause bleeding or damage to their oral tissues. The nurse should inspect the child's mouth for any injuries and provide appropriate care.
Correct Answer is B
Explanation
The correct answer is B. Diminished pulses on the affected extremity indicate impaired circulation, which can lead to tissue ischemia, necrosis, and compartment syndrome if not corrected promptly. This is a life-threatening complication that requires immediate intervention such as loosening or cutting off the cast, elevating the limb, or administering vasodilators. The other findings are not as urgent, although they may indicate other problems such as hematoma, infection, or nerve injury that need further assessment and treatment.
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