A term multigravida, who is receiving oxytocin IV for labor augmentation, is requesting pain medication. Review of the client's record indicates that she was medicated 30 minutes ago with butorphanol 2 mg and promethazine 25 mg IV push. Vaginal examination reveals that the client's cervical dilation is 3 cm, 10% eﬀaced, and at a 0 station. Which action should the practical nurse (PN) implement?

Coach the client to take slow, deep breaths during each contraction.

Report to the nurse that the client needs another dose of butorphanol.

Notify the healthcare provider.

Discontinue the oxytocin infusion.

Answer and Explanation

The Correct Answer is A

In this situation, the practical nurse (PN) should coach the client to take slow, deep breaths during each contraction. The client has already been medicated with butorphanol and promethazine for pain relief and it may not be appropriate to administer another dose at this time. Instead, the PN can provide non- pharmacological pain relief measures such as coaching the client to use breathing techniques to help manage the pain during contractions. The other actions listed may also be appropriate in some situations, but coaching the client to use breathing techniques is the most appropriate action in this situation.

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Correct Answer is B

Explanation

Placenta previa is a condition in which the placenta partially or completely covers the cervix, which can lead to vaginal bleeding during pregnancy. In severe cases, this bleeding can be life-threatening and can lead to hemorrhage. Therefore, the PN should closely monitor the client for any signs of bleeding or hemorrhage, such as excessive vaginal bleeding, hypotension, tachycardia, or signs of shock. The PN should also ensure that the client receives appropriate medical interventions and that emergency measures are in place in case of sudden bleeding or hemorrhage.

A. Take the vital signs and open the IV infusion rate of oxytocin. B. Notify the registered nurse (RN) that the client's bladder is distended. C. Put the infant to breast to suckle and stimulate oxytocin secretion. D. Massage the fundus and expel retained lochia and clots.

Correct Answer is D

Explanation

The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.

Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.

Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.

Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is multiparous at 36-weeks gestation is diagnosed with placenta previa. The practical nurse (PN) should monitor this client for which condition?

Correct Answer is B

Explanation

A patient is admitted to the postpartum unit one hour after a sterile vaginal delivery of a normal neonate weighing 8 pounds 2 ounces (3.7 kg). When the client's fundus becomes boggy and displaced above the umbilicus, which action should the practical nurse (PN) take first?

Correct Answer is D

Explanation

A highly successful businessman presents to a mental health center complaining of sleeplessness and anxiety over his financial status. Which action should the practical nurse (PN) take to assist this client in diminishing his anxiety?

The practical nurse (PN) is caring for a client in the preoperative holding area who is waiting for abdominal surgery. The client tells the PN about feeling afraid and anxious because of the surgery. Which technique is best for the PN to assist the client to use while waiting for surgery?

During a well-baby clinic visit, a mother tells the practical nurse (PN) that her 12-month-old infant is not yet eating solid foods and drinks whole milk from a bottle. Based on these assessment findings, this infant is at the greatest risk for developing which condition?

A male client with paranoia has been admitted to the mental health unit, and upon arrival, he immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?

During morning rounds, a client who is admitted with obsessive-compulsive disorder is in the dayroom repeatedly washing the top of the same table. Which intervention should the practical nurse (PN) implement when approaching the client?

The client tells the practical nurse (PN), "I have been applying triple antibiotic ointment to my athlete's foot for the past two days, but it still itches. How should the PN respond?

The practical nurse (PN) is assigned to assist in the care of a laboring client at 42-weeks gestation. While providing perineal care, the PN observes the umbilical cord protruding from the vagina. Which action should the PN take?