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.

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Correct Answer is C

Explanation

A) The client will progress one station every 2 hours:
This statement is inaccurate. The progress of labor in terms of fetal station does not follow a predictable or uniform rate. While some progression might occur every hour or two, it varies greatly depending on factors such as the position of the fetus, maternal anatomy, and strength of contractions. Labor can progress at different rates, and not all clients will experience consistent progression every 2 hours.

B) The client should feel the urge to push at -2 station:
This statement is incorrect. The urge to push generally occurs once the fetal head has descended to +1 or +2 station, which is closer to the perineum. At -2 station, the fetal head is still relatively high in the pelvis, and the client typically will not feel the urge to push until the head is lower. The urge to push is often experienced when the fetal head is well engaged in the pelvis and ready for delivery.

C) The client's temperature will need to be checked every hour when the membranes have ruptured:
This statement is correct. Once the membranes have ruptured, there is an increased risk of infection, as the protective barrier of the amniotic sac is no longer intact. Checking the maternal temperature every hour is an essential practice to monitor for signs of infection, such as chorioamnionitis, especially since the longer the rupture lasts, the greater the risk of infection. A rise in temperature is a key indicator of infection in the postpartum period.

D) The client's cervix will need to be checked every 30 minutes:
This is not correct practice. Cervical checks should be performed only when clinically indicated, not routinely every 30 minutes. Frequent cervical checks can increase the risk of infection, especially after the membranes have ruptured. The cervix should be assessed when there is a clinical reason to do so, such as checking for progress in labor or when considering interventions like an epidural or pushing.

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.

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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 teaching a student nurse about the anticipated care of a maternal client with ruptured membranes during the second stage of labor. Which of the following statements by the student indicates an understanding of the teaching?

Correct Answer is C

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

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