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 D
Explanation
When a Rh-negative mother gives birth to a Rh-positive baby, there is a risk that the mother's immune system will develop antibodies against the Rh-positive factor. These antibodies can cross the placenta in future pregnancies and atack the Rh-positive fetus, leading to hemolytic disease of the newborn. Rho(D) immune globulin is given after delivery to prevent the formation of these antibodies. The PN should explain this to the client and encourage her to reconsider her refusal of the treatment. Answers A, B, and C are incorrect and do not provide accurate information.
Correct Answer is C
Explanation
Answer: B. Limit play with the stuffed toy when out of the tent.
Rationale:
A) Spray the toy with disinfectant before placing it in the tent: Disinfecting the toy may not be necessary unless the toy is visibly soiled. Moreover, the use of disinfectants around the child may pose a risk of respiratory irritation, making this option inappropriate.
B) Limit play with the stuffed toy when out of the tent: This action is appropriate as it helps minimize the risk of cross-contamination and reduces exposure to potential allergens or irritants that may worsen the child's condition. Keeping the toy limited to the tent allows for a safer environment for the child.
C) Allow the child to have the stuffed toy in the tent: While having a favorite toy can provide comfort, it’s crucial to ensure that the toy does not harbor germs that could exacerbate the child's illness. In a mist tent, moisture can also promote mold growth on soft toys, so extra caution is necessary.
D) Ask the mother to wash the toy daily at home: While washing the toy is a good practice, this option does not directly address the immediate care in the hospital setting. Daily washing might not be feasible for the mother during the hospital stay, and it does not focus on minimizing exposure during the child’s hospitalization.
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