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:
Placing a covering on the scale tray when weighing an infant helps to ensure that conductive heat loss from the infant is minimal. Newborns and infants are especially vulnerable to temperature changes, and maintaining their body temperature is crucial for their well-being. By placing a covering, such as a soft cloth or blanket, on the scale tray, the nurse creates a barrier between the infant's skin and the cold surface of the scale. This reduces the risk of heat loss from direct contact with the scale, helping to keep the baby comfortable and preventing any potential adverse effects from exposure to low temperatures during the weighing process.
Choice B reason:
Choice B, compensating for the negative weight balance to ensure the correct weight, is not the primary reason for using a covering on the scale tray. The negative weight balance, if any, would be minimal and not significant enough to affect the accuracy of the infant's weight measurement. The main concern when using a scale for weighing infants is to ensure their comfort and safety during the process.
Choice C reason:
Choice C, avoiding causing multiple startle (Moro) reflexes when weighing, is not the main reason for using a covering on the scale tray. The Moro reflex is a normal startle response in infants and is not typically affected by whether or not a covering is placed on the scale tray.
The nurse can support the infant appropriately during weighing to minimize any startle reflexes, regardless of whether a covering is used.
Choice D reason:
Choice D, avoiding contaminating the nurse's hands with blood or other body substances, is not directly related to using a covering on the scale tray. The primary purpose of using a covering is to minimize heat loss, as explained in Choice A. However, it is standard practice for healthcare professionals to wear gloves when handling blood or body substances to prevent any potential transmission of infections, ensuring both the nurse's and the infant's safety.
Correct Answer is D
Explanation
Choice A reason:
10% to 15% of their birth weight. This is incorrect because this range is too high for a normal newborn weight loss. Losing more than 10% of their birth weight may indicate dehydration, inadequate feeding, or other problems. • Choice B reason:
20% of their birth weight. This is incorrect because this percentage is way too high for a normal newborn weight loss. Losing 20% of their birth weight would be a serious sign of illness or malnutrition. • Choice C reason:
15% to 18% of their birth weight. This is incorrect because this range is also too high for a normal newborn weight loss. Losing 15% to 18% of their birth weight would be a cause for concern and require further evaluation. • Choice D reason:
5% to 10% of their birth weight. This is correct because this range is within the normal limits for a newborn weight loss. Newborns lose some weight as a result of insufficient caloric intake, fluid loss, and metabolic adjustments in the first week after birth. They usually regain their birth weight by the second week.
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