The nurse is caring for a client with contractions every 2-3 minutes, moderate to palpation, with a duration of 45-60 seconds. The client is having a difficult time breathing through contractions and is requesting something for pain. The client is 5 cm dilated, 80% effaced, and at a -1 station.

Which pain relief measure would be most effective for this client?

Epidural

Effleurage

Opioids

Sedatives

Answer and Explanation

The Correct Answer is A

A.   An epidural provides comprehensive pain relief by blocking sensation from the waist down, making it an effective option for clients experiencing intense pain during labor.
B.   Effleurage (massage or light stroking) may provide some comfort but may not be sufficient for the described level of pain.
C.   Opioids can provide pain relief but may not be as effective in managing the intense pain of contractions in active labor.
D.   Sedatives may not be the best choice during active labor as they can have a sedating effect on both the mother and the baby, potentially affecting the progress of labor.

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Correct Answer is D

Explanation

A. A FHR baseline of 125 is within the normal range for a fetal heart rate.

B. A temperature of 99.9°F is a mild elevation and may not be an immediate concern.

C. Blood pressure of 142/90 may be elevated but may not require immediate action unless associated with other concerning symptoms.
D. Contractions lasting 45-60 seconds are prolonged and may lead to decreased fetal oxygenation. This finding should be reported immediately to the charge nurse.

A. "It will cause your contractions to slow down so we can give you steroids." B. "It will cause an increased blood flow through the placenta." C. "It will cause an increase in urinary output." D. "It will cause your uterus to contract to speed up your labor."

Correct Answer is D

Explanation

A. Oxytocin is administered to enhance contractions, not to slow them down.

B. While increased blood flow through the placenta is important for fetal well-being, oxytocin is primarily used to stimulate uterine contractions.
C. Increased urinary output is not the primary effect of oxytocin; its main action is to stimulate uterine contractions.

D. Oxytocin is commonly used to induce or augment labor by stimulating contractions of the uterus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in labor. Which assessment finding will the nurse report to the charge nurse immediately?

Correct Answer is D

Explanation

The nurse is caring for a client in labor receiving oxytocin. The client asks the nurse, "What is this medication for?" What is the best response by the nurse?

Correct Answer is D

Explanation

The nurse takes a phone call from a client at two weeks postpartum. The client states, "My left breast hurts." What other question will the nurse ask her to determine if it is mastitis?

The nurse is caring for a client during a vaginal exam by the provider. The provider informs the client that he will use the most common mechanical method to ripen her cervix prior to induction of labor. What is the method being used by the provider?

The nurse has received shift report for five clients admitted in labor. Which clients will the nurse anticipate delivering by a cesarean section? Select all that apply.

The nurse is admitting a pregnant client into the labor and delivery unit. Which findings indicate the client is in the latent phase of the first stage of labor? Select all that apply.

The nurse is assisting a pregnant patient into bed after the patient reports a gush of fluid from the vagina. Which action will the nurse take first?

The nurse is caring for a client in labor and discovers late decelerations of the fetal heart rate. What does the nurse know as the reason for this type of deceleration?

A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson’s developmental stages should the nurse consider in the planning?

The nurse is caring for a client in labor. Which process will the nurse use to determine the duration of contractions?