A nurse is working with a client who is 6 hour postpartum following a vaginal birth with first -degree laceration. Which of the following, actions is an example of the nurse providing a stepwise approach to manage the client's pain?

Offering opioids followed by topical treatment!

Offering mindfulness only for pain

Giving the ghest dose of opioids to make sure to eliminate the pain

Starting with ibuprofen for pain management and adding cold therapy for additional relief.

Answer and Explanation

The Correct Answer is D

A) Offering opioids followed by topical treatment:
While opioids can be effective for pain, they are typically reserved for more severe pain and are not the first line of treatment for the moderate pain commonly experienced postpartum, especially after a first-degree laceration. A stepwise approach emphasizes starting with less potent options and progressing as needed, so offering opioids first is not appropriate here.

B) Offering mindfulness only for pain:
While mindfulness and other non-pharmacological techniques can be helpful for pain management, offering only mindfulness as the sole approach may not adequately address the client's pain, especially in the early postpartum period. A stepwise approach typically involves combining pharmacological and non-pharmacological methods to achieve effective pain relief, so relying only on mindfulness is not the most effective strategy for this situation.

C) Giving the highest dose of opioids to make sure to eliminate the pain:
Stepwise pain management involves starting with the least invasive and least potent option, such as nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, and escalating treatment if necessary. Using high doses of opioids first can lead to unnecessary side effects and risks, especially when less potent options would suffice.

D) Starting with ibuprofen for pain management and adding cold therapy for additional relief:
This is an example of a stepwise approach to pain management. Starting with ibuprofen, an NSAID, addresses inflammation and mild to moderate pain effectively, which is appropriate for a first-degree laceration. Cold therapy can be added for additional relief, as it helps reduce swelling and numb the area, which can further reduce discomfort. This combination of pharmacological and non-pharmacological treatments follows the principle of starting with less potent options and adding more if needed, making it the best choice.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A) Decrease the client's IV fluids:
Sinusoidal fetal heart rate patterns are concerning and typically indicate severe fetal distress, which is often associated with conditions such as fetal anemia, hypoxia, or central nervous system (CNS) damage. Decreasing IV fluids is not an appropriate response to a sinusoidal pattern. The primary focus should be on fetal well-being, not fluid management, in this situation.

B) Prepare the client for an emergent birth:
This pattern is typically associated with severe fetal compromise and is an ominous sign. Immediate intervention is required, and emergent delivery may be necessary to prevent further fetal distress and potential harm. The nurse should promptly notify the healthcare provider and prepare the client for an emergency cesarean delivery or other urgent interventions.

C) Turn the client to a supine position:
The supine position is not recommended for managing fetal distress, as it may decrease uterine blood flow and worsen the situation, especially if the fetus is experiencing hypoxia. The appropriate intervention for addressing a sinusoidal heart rate pattern is not repositioning the client in a supine position, but rather preparing for emergency delivery and providing immediate support to stabilize both mother and fetus.

D) Document the findings:
While it is important to document any fetal heart rate pattern, sinusoidal patterns require immediate action. Documentation alone is not sufficient in this case, as it does not address the potential life-threatening situation for the fetus. The nurse should not delay action, and the focus should be on preparing for emergency birth and notifying the healthcare provider immediately.

A. Dry and stimulate newborn with towel. B. Place a hat on the newborn's head. C. Maintain the delivery room temperature at 20° C (68° F) D. Place a blanket on top of maternal dent and newborn.

Correct Answer is C

Explanation

A) Dry and stimulate newborn with towel:
Drying and stimulating the newborn immediately after birth is a standard practice to prevent heat loss and promote early bonding. This action helps to prevent heat loss through evaporation and stimulates the newborn to breathe. It is an appropriate intervention to reduce the risk of hypothermia, not increase it.

B) Place a hat on the newborn's head:
Placing a hat on the newborn’s head is an appropriate and helpful intervention. Since a significant amount of heat is lost through the head, especially in newborns who have a larger surface area relative to their body mass, keeping the head covered with a hat helps to retain warmth and reduce the risk of hypothermia. This would not place the newborn at risk for hypothermia.

C) Maintain the delivery room temperature at 20° C (68° F):
A delivery room temperature of 20° C (68° F) is on the lower end of the recommended range for newborn care. Newborns are particularly susceptible to heat loss due to their high surface area-to-body weight ratio and immature thermoregulation system. A cooler environment like 20°C increases the risk of hypothermia, as the newborn will lose heat more quickly than it can generate on its own.

D) Place a blanket on top of maternal and newborn:
Placing a blanket over the mother and newborn is an appropriate intervention to prevent heat loss. This promotes warmth by reducing heat loss from the newborn's body surface to the cooler environment. This would not place the newborn at risk for hypothermia; instead, it helps to maintain body temperature.

View Question and Answer

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

A nurse is working with a client who is 6 hour postpartum following a vaginal birth with first -degree laceration. Which of the following, actions is an example of the nurse providing a stepwise approach to manage the client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is analyzing a fetal heart monitor strip and identifies a sinusoidal fetal heart rate pattern, which has been occurring for 30 min. Which of the following actions should the nurse take at this time?

Correct Answer is B

Explanation

A nurse is caring for a client who has their newborn placed skin to skin immediately following birth with a temperature of 37° C (98.6" F). Which of the following interventions by the nurse would place the newborn at higher risk for hypothermia?

Correct Answer is C

Explanation

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

The pregnant client term has in presented in the early phase of labor. She is experiencing abdominal pain and shows signs of growing anxiety about pain. What is the best pain management technique the nurse can suggest at this stage?

Which of the following is an example of a primitive reflex that is present in newborns and typically disappears by 3-4 months of age?

A nurse is discussing probable signs of pregnancy with a newly licensed nurse. Which of the following terms should the nurse use to describe the movement of the fetus felt by the provider after placing upward pressure on the cervix?

When assessing a newborn shortly after birth, the nurse finds flat, irregular pinkish marks the forehead, the nape of the neck and the eyelids. The areas blanch when pressed with a finger. The nurse would document this finding as:

A nurse is working with a client who is 6 hour postpartum following a vaginal birth with first -degree laceration. Which of the following, actions is an example of the nurse providing a stepwise approach to manage the client's pain?