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 B
Explanation
The best indicator to the practical nurse (PN) that the community bicycle safety education program was effective is that the number of students wearing bicycle helmets increased by 10%. Wearing a helmet while riding a bicycle is an important safety measure that can help prevent head injuries in the event of an accident. An increase in the number of students wearing helmets indicates that the program was successful in promoting this safety behavior. The other findings listed may also provide useful information about the effectiveness of the program, but the increase in helmet use is the most direct and measurable indicator of success.
Correct Answer is A
Explanation
This can offer a safe place for her and her unborn child. The shelter can also provide resources for counseling and legal assistance if needed.
The safety plan and restraining order are important measures, but the priority should be to ensure the client's immediate safety.
The visit summary documenting the report of abuse is also important, but it should not be the only information provided to the client.
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