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
Gestational diabetes mellitus (GDM) is a type of diabetes that occurs during pregnancy. If euglycemia, or normal blood glucose levels, is not maintained during pregnancy, the fetus can be at risk for a number of complications. The greatest risk to the fetus in this situation is the development of a macrosomic newborn, or a newborn that is significantly larger than average. This occurs because the excess glucose in the mother's bloodstream is passed on to the fetus, leading to excessive fetal growth.
Macrosomia can lead to complications during delivery, such as shoulder dystocia, and can increase the risk of injury to both the mother and the baby. While low birth weight and preterm birth are also potential complications of GDM, macrosomia is considered the greatest risk to the fetus if euglycemia is not maintained. Cleft palate is not typically associated with GDM.
Correct Answer is A
Explanation
Flaring of the nares, or widening of the nostrils, is a sign of respiratory distress in infants. It indicates that the child is working harder to breathe. This finding should alert the practical nurse (PN) that the child with bronchiolitis is in acute respiratory distress.
A resting respiratory rate of 35 breaths/minute (B) is within the normal range for a 3-month-old infant. Bilateral bronchial breath sounds (C) and diaphragmatic respirations (D) are not specific signs of acute respiratory distress in infants.
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