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
This is because epidural anesthesia can cause hypotension (low blood pressure) which can affect the placental blood flow and fetal oxygenation.
The nurse should monitor the patient’s blood pressure frequently and intervene if it drops below the baseline.
Choice A is wrong because assessing the patient’s urine for acetone is not relevant to the side effects of epidural anesthesia.Acetone in urine can indicate diabetic ketoacidosis, a complication of diabetes that occurs when the body breaks down fat for energy due to lack of insulin.
However, this is not related to epidural anesthesia.
Choice B is wrong because monitoring the patient’s deep tendon reflexes is not relevant to the side effects of epidural anesthesia.Deep tendon reflexes can be affected by magnesium sulfate, a medication used to prevent seizures in patients with preeclampsia (a condition characterized by high blood pressure and proteinuria in pregnancy).
However, this is not related to epidural anesthesia.
Choice C is wrong because assessing the patient’s pupillary accommodation is not relevant to the side effects of epidural anesthesia.
Pupillary accommodation is the ability of the eye to adjust its focus from distant to near objects.It can be impaired by drugs that affect the nervous system, such as opioids or anticholinergics.
Correct Answer is C
Explanation
This is because urine toxicology studies can detect the presence of cocaine and other drugs in the body of the pregnant woman and her unborn baby.Cocaine use during pregnancy can have serious consequences for both the mother and the baby, such as high blood pressure, premature labor, low birth weight, and developmental problems.
Choice A is wrong because urine estriol levels are used to measure the activity of the placenta and the fetal adrenal glands.They are not related to cocaine use.
Choice B is wrong because serum bilirubin levels are used to assess the liver function and the risk of jaundice in newborns.They are not related to cocaine use.
Choice D is wrong because lecithin-sphingomyelin ratio is used to evaluate the fetal lung maturity and the risk of respiratory distress syndrome.It is not related to cocaine use.
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