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 C
Explanation
During gastrostomy (GT) feedings for a newborn infant with a tracheo-esophageal repair, the practical nurse (PN) should offer a pacifier to satiate the sucking reflex associated with feedings. Sucking is a natural reflex for infants and providing a pacifier during feedings can help satisfy this need and promote comfort. The other interventions listed may also be important to implement during GT feedings, but offering a pacifier to satiate the sucking reflex is the most appropriate intervention in this situation.
Correct Answer is D
Explanation
An increasing trend in maternal heart rate is a sign of fetal distress, which can be a serious complication of PROM. One of the primary interventions for fetal distress is to increase oxygen delivery to the fetus. The practical nurse should initiate oxygen via face mask at 8 to 10 L/min to improve fetal oxygenation.
Contact precautions may be necessary for certain conditions, but they are not indicated for an increasing maternal heart rate.
Inserting a urinary catheter may be appropriate for monitoring output, but it is not the first priority in this situation.
Encouraging the client to push is not appropriate because the client is not in active labor and pushing can cause further complications.
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