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
If the practical nurse (PN) is caring for a client who delivered 6 hours ago and assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus, the PN should encourage the client to void. A full bladder can displace the uterus and prevent it from contracting properly, leading to a boggy uterus. Encouraging the client to void can help empty the bladder and allow the uterus to contract and return to its normal position. The other actions listed may also be appropriate in some situations, but encouraging voiding is the most appropriate action in this situation.
Correct Answer is D
Explanation
The newborn assessment finding that the practical nurse (PN) should report to the charge nurse immediately for a 24-hour-old infant is a heart rate of 100 beats/minute. The normal heart rate for a newborn is between 120-160 beats/minute. A heart rate of 100 beats/minute is below the normal range and may indicate a problem such as hypothermia or an infection. The PN should report this finding to the charge nurse immediately so that appropriate action can be taken to address the issue. The other assessment findings listed may also be important to monitor, but a heart rate of 100 beats/minute is the most urgent and requires immediate attention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today