A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
Assist the client with breathing and imagery techniques in an attempt to calm her down.
Ask the client to describe the intensity of her pain on a scale of 0 to 10.
Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication.
Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk.
The Correct Answer is A
Choice A reason:
This is the best response because it shows that the nurse is providing nonpharmacological pain relief measures and supporting the client's coping mechanisms. Breathing and imagery techniques can help the client relax and focus on something other than the pain. Moaning, screaming, and vocalizing are normal and acceptable ways of expressing pain during labor, and the nurse should not try to suppress them.
Choice B reason:
This is not the best response because it does not address the husband's concern or offer any intervention for the client's pain. Asking the client to rate her pain on a scale of 0 to 10 is a subjective assessment tool that may not reflect the true intensity of her pain. Furthermore, it may be difficult for the client to answer this question while she is in the second stage of labor.
Choice C reason:
This is not the best response because it may not be feasible or appropriate to administer more pain medication to the client in the second stage of labor. The obstetrician may not be available to evaluate the client's pain, and increasing the dose of pain medication may have adverse effects on the client and the fetus, such as respiratory depression, hypotension, and decreased uterine contractility.
Choice D reason:
This is not the best response because it does not acknowledge the husband's feelings or provide any comfort or education for him. Reassuring him that his wife will be fine may sound dismissive and insensitive, and offering to stay with her while he takes a walk may imply that he is not needed or wanted in the birthing room. The nurse should involve the husband in the care of his wife and explain to him what is happening and what to expect during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Uteroplacental insufficiency is a condition where the placenta cannot deliver enough oxygen and nutrients to the fetus. This can cause fetal hypoxia and distress, which can be detected by late decelerations on the fetal heart rate monitor. Late decelerations are defined as a decrease in the fetal heart rate that begins after the peak of the contraction and returns to baseline after the contraction ends. This indicates that the fetus is not tolerating the reduced blood flow during the contractions and needs immediate intervention. • Choice B reason:
Umbilical cord compression is a condition where the umbilical cord is squeezed or twisted, reducing the blood flow and oxygen to the fetus. This can cause variable decelerations on the fetal heart rate monitor. Variable decelerations are defined as a decrease in the fetal heart rate that varies in timing, shape, and duration, and may or may not be associated with contractions. This indicates that the fetus is experiencing intermittent or sustained cord compression and may need repositioning or other interventions. • Choice C reason:
Maternal bradycardia is a condition where the mother's heart rate is slower than normal, usually less than 60 beats per minute. This can cause reduced blood flow and oxygen to the placenta and the fetus, but it does not cause late decelerations on the fetal heart rate monitor. Maternal bradycardia can be caused by various factors, such as medications, hypothermia, hypothyroidism, or vagal stimulation. It may need treatment depending on the cause and severity. • Choice D reason:
Fetal head compression is a condition where the fetal head is pressed against the cervix or the pelvic floor during labor, stimulating the vagus nerve and slowing down the fetal heart rate. This can cause early decelerations on the fetal heart rate monitor. Early decelerations are defined as a decrease in the fetal heart rate that begins with the onset of the contraction and returns to baseline with the end of the contraction. This indicates that the fetus is descending in the birth canal and is usually a normal and benign finding.
Correct Answer is C
Explanation
Choice A reason:
Assisting the client on a bedpan to urinate is important for assessing urinary output and preventing bladder distension. However, in this situation, the priority is to assess and manage postpartum hemorrhage, which is indicated by the excessive bleeding.
Choice B reason:
Increasing the client's fluid intake is generally a good measure for promoting hydration and maintaining blood volume. However, it is not the priority in this scenario of excessive postpartum bleeding.
Choice C reason:
Palpating the client's uterine fundus is the priority nursing intervention at this time. The excessive bleeding indicated by saturating two perineal pads in a 30-minute period suggests postpartum hemorrhage, which can result from uterine atony (failure of the uterus to contract adequately after childbirth). Palpating the fundus allows the nurse to assess if the uterus is firm or boggy, and if it is not contracting properly, immediate interventions can be initiated to control the bleeding.
Choice D reason:
Preparing to administer oxytocic medication (such as oxytocin) can help stimulate uterine contractions and prevent or manage postpartum hemorrhage. However, the priority is to first assess the uterine fundus and confirm the cause of the excessive bleeding before administering any medication.
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