A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions.
Which of the following actions should the nurse take?
Apply fundal pressure during contractions.
Instruct the client to change positions frequently.
Tell the client to push during contractions.
Encourage the client to soak in a hot bath.
The Correct Answer is B
Explanation
B. Instruct the client to change positions frequently
Encouraging the client to move around, walk, change positions during labour can help relieve discomfort, promote optimal fetal positioning positions, or use a birthing ball can help alleviate pelvic pain and potentially facilitate the progress of labour.
Applying fundal pressure during contractions in (option A) is not necessary during the latent stage of labour. Fundal pressure is typically used in the active stage of labour to assist with the descent and positioning of the baby's head.
Telling the client to push during contractions in (option C) is not appropriate during the latent stage of labour. Pushing is typically reserved for the second stage of labour when the cervix is fully dilated.
Encouraging the client to soak in a hot bath in (option D) is not recommended during labour, particularly in the hospital setting. Immersion in hot water (e.g., a hot bath) can increase the risk of infection and is generally not recommended until after the birth of the baby
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Observing the client during and after meals is crucial for monitoring their eating behaviors, identifying any signs of bingeing or purging, and assessing their overall progress in managing their eating disorder. By closely observing the client, the nurse can provide immediate support and intervention if necessary and help prevent or address any potentially harmful behaviors. Instructing the client about effective coping strategies is valuable in helping them develop healthier ways to manage stress and emotions. However, this instruction can be more effective once the nurse has observed the client's behaviors and identified specific areas where coping strategies are needed.
Suggesting that the client assist with meal planning can be a helpful step in empowering them to take ownership of their eating habits and make healthier choices. However, before involving the client in meal planning, it is important to first assess their current eating behaviors and address any immediate concerns or risks.
Referring the client to a support group for individuals with eating disorders is a beneficial step in providing ongoing support and community. However, this referral can be made once the nurse has established a baseline understanding of the client's behaviors and needs.
Observing the client during and after meals is crucial for monitoring their eating behaviors, identifying any signs of bingeing or purging, and assessing their overall progress in managing their eating disorder. By closely observing the client, the nurse can provide immediate support and intervention if necessary and help prevent or address any potentially harmful behaviors. Instructing the client about effective coping strategies is valuable in helping them develop healthier ways to manage stress and emotions. However, this instruction can be more effective once the nurse has observed the client's behaviors and identified specific areas where coping strategies are needed.
Suggesting that the client assist with meal planning can be a helpful step in empowering them to take ownership of their eating habits and make healthier choices. However, before involving the client in meal planning, it is important to first assess their current eating behaviors and address any immediate concerns or risks.
Referring the client to a support group for individuals with eating disorders is a beneficial step in providing ongoing support and community. However, this referral can be made once the nurse has established a baseline understanding of the client's behaviors and needs.

Correct Answer is D
Explanation
Hyperkalemia refers to an elevated level of potassium in the blood. It can have various manifestations, and one of the critical effects of hyperkalemia is its impact on cardiac function. High levels of potassium can disrupt the normal electrical conduction in the heart, leading to arrhythmias or irregular heart rate. These arrhythmias can range from mild palpitations to more severe and life-threatening conditions like ventricular fibrillation.
Dry mucous membranes are more commonly associated with dehydration or reduced fluid intake. Hyperkalemia does not directly cause dry mucous membranes.
Trousseau's sign is a clinical manifestation of hypocalcemia, not hyperkalemia. It is characterized by carpal spasm induced by inflating a blood pressure cuff above the client's systolic blood pressure for a few minutes.
Hyperactive reflexes are commonly seen in conditions such as hyperthyroidism or certain neurologic disorders. They are not directly related to hyperkalemia.
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