nurse hears a client in active labor say to her husband, “Don’t touch me.
Stay away.” The husband states, “I don’t know what to do. Everything I do is wrong.” Which response by the nurse would be the most supportive?
“Would you like to take a break for a while?”.
“You are doing a great job.
It’s very difficult to support someone during this part of labor.”.
“Perhaps she’ll respond better to someone else.
Can you call someone to help?”.
The Correct Answer is B
The correct answer is choice B. “You are doing a great job.
It’s very difficult to support someone during this part of labor.” This response acknowledges the husband’s feelings and efforts, and provides reassurance and encouragement.
It also reflects the reality that active labor can be very intense and painful for the woman, and she may not want to be touched or talked to.
Choice A is wrong because it suggests that the husband is not needed or wanted, and may make him feel rejected or useless.
Choice C is wrong because it implies that the husband is not a good support person, and may hurt his self-esteem or damage his relationship with his wife.
Choice D is wrong because it focuses on the physical aspect of labor, rather than the emotional one.
It also assumes that the woman wants medication, which may not be the case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. “Have you noticed any tenderness in your breasts?”
Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception.It is caused by hormonal changes that prepare the breasts for lactation.
Choice A is wrong because shortness of breath is not a sign of early pregnancy.It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.
Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy.They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.
Choice C is wrong because spotting is not a sign of early pregnancy.
It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus.However, implantation bleeding is usually much lighter and shorter than a normal period.
Correct Answer is D
Explanation
The correct answer is choice D. Decreased respirations.Magnesium sulfate is a medication that can causerespiratory depression, which means it can slow down or stop breathing.
This is a serious side effect that needs to be monitored closely by the nurse.
Choice A is wrong because increased Babinski reflex is not a side effect of magnesium sulfate.
The Babinski reflex is a normal response in infants, but abnormal in adults.
It occurs when the big toe bends upward and the other toes fan out when the sole of the foot is stroked.Magnesium sulfate can causepoor reflexes, but not specifically the Babinski reflex.
Choice B is wrong because diarrhea is not a side effect of magnesium sulfate when given intravenously or intramuscularly.Diarrhea can occur when magnesium sulfate is taken orally as a laxative, but that is not the case in this question.
Choice C is wrong because tetany is not a side effect of magnesium sulfate.
Tetany is a condition that causes muscle spasms and cramps due to low levels of calcium in the blood.Magnesium sulfate can actually causehypocalcemia, which means low levels of calcium in the blood, but this does not usually result in tetany.Tetany is more likely to occur when there is low magnesium in the blood, which is calledhypomagnesemia.
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