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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Newborns have a stump of the umbilical cord attached to their belly button which eventually falls off within 1-2 weeks. During this time, it is important to keep the area clean and dry to prevent infection. The PN should instruct the parents to clean the area with water and a clean cloth or cotton swab, and then gently pat the area dry with a clean towel. The parents should also be advised to avoid using any harsh soaps, lotions, or alcohol on the cord stump, as this can cause irritation or delay the healing process. It is not recommended to cover the cord stump with a sterile dressing unless specifically instructed to do so by a healthcare provider.
Correct Answer is B
Explanation
This is the most appropriate intervention for the PN to implement when approaching a client who is exhibiting compulsive behavior. By allowing time for the behavior, the PN acknowledges the client's need to perform the behavior and avoids creating further stress for the client. Redirecting the client to other activities can also help to refocus the client's behavior and prevent further compulsive behavior.
Encouraging the client to be calm and relax for a little while (A) may not be effective in managing the compulsive behavior.
Teaching the client thought-stopping techniques and ways to refocus behaviors (C) and assisting the client to identify stimuli that precipitate the activity (D) are interventions that may be used in the long term, but they may not be immediately effective in managing the client's behavior in the moment.
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