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 []
Explanation
The diagram should be completed as follows:
Condition Most Likely Experiencing: B. Respiratory distress syndrome. Action to Take 1: C. Administer Surfactant as prescribed. Action to Take 2: Provide oxygen therapy as needed. Parameter to Monitor 1: B. Arterial blood gases. Parameter to Monitor 2: D. Oxygen saturation.
Conditions Explained
Choice A reason:
Hypoglycemia is a condition where the blood glucose level is too low. It can cause symptoms
such as jitteriness, lethargy, poor feeding, and seizures. However, hypoglycemia does not
explain the respiratory signs that the newborn is experiencing, such as tachypnea, grunting,
nasal flaring, and retractions. Acrocyanosis is also not a sign of hypoglycemia. Therefore,
choice A is incorrect.
Choice B reason:
Respiratory distress syndrome (RDS) is a condition where the lungs are not fully developed
and lack enough surfactant, a substance that helps the alveoli stay open and exchange
oxygen and carbon dioxide. It can cause symptoms such as tachypnea, grunting, nasal flaring,
retractions, and cyanosis. RDS is more common in premature infants, especially those born
before 37 weeks of gestation. Acrocyanosis can be a normal finding in the first 24 hours of
life, but it can also indicate poor perfusion due to respiratory compromise. Therefore, choice
B is the most likely condition that the newborn is experiencing.
Choice C reason:
Neonatal abstinence syndrome (NAS) is a condition where the newborn withdraws from
drugs that were exposed in utero. It can cause symptoms such as irritability, tremors, high-
pitched crying, poor feeding, vomiting, diarrhea, and sweating. However, NAS does not
explain the respiratory signs that the newborn is experiencing, such as tachypnea, grunting,
nasal flaring, and retractions. Acrocyanosis is also not a sign of NAS. Therefore, choice C is
incorrect.
Choice D reason:
Jaundice is a condition where the skin and sclerae turn yellow due to excess bilirubin in the
blood. It can be caused by various factors such as blood group incompatibility, hemolysis,
infection, or liver dysfunction. However, jaundice does not explain the respiratory signs that
the newborn is experiencing, such as tachypnea, grunting, nasal flaring, and retractions.
Acrocyanosis is also not a sign of jaundice.
Correct Answer is C
Explanation
Choice A reason:
Occasional uterine cramping when the infant nurses is a normal phenomenon that occurs as the uterus contracts and returns to its pre-pregnancy size. This is not a sign of infection or complication and does not need to be reported.
Choice B reason:
Descent of the fundus one fingerbreadth each day is also a normal finding that indicates the uterus is involuting properly. The fundus is the top of the uterus that can be felt through the abdomen. It should be at the level of the umbilicus immediately after delivery and then descend about one fingerbreadth (or 1 cm) each day until it reaches the pelvic brim by 10 days postpartum.
Choice C reason:
Reappearance of red lochia after it changes to serous is an abnormal sign that may indicate uterine atony, subinvolution, or retained placental fragments. Lochia is the vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue. It usually changes from red to pink to brown to yellow-white over a period of several weeks. If it becomes red again, it may mean that there is bleeding from the uterus or infection in the endometrium. This should be reported to a health care provider as soon as possible.
Choice D reason:
Oral temperature that is 37.2 C (99 F) in the morning is within the normal range and does not indicate fever or infection. A slight elevation in temperature may occur due to dehydration, breast engorgement, or hormonal changes. This does not need to be reported unless it exceeds 38 C (100.4 F) or persists for more than 24 hours.
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