A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management measures should the nurse identify as a safe option for the client?
Butorphanol tartrate
Pudendal block
Naloxone hydrochloride
Spinal anesthesia
The Correct Answer is B
Rationale:
A. Butorphanol tartrate: This opioid analgesic can cause respiratory depression in the newborn if given too close to delivery. At 10 cm dilation and during pushing, it's generally too late to administer systemic opioids safely.
B. Pudendal block: A pudendal block provides localized perineal anesthesia and is safe for use during the second stage of labor when the client is fully dilated and pushing. It effectively reduces pain from stretching and pressure without affecting uterine contractions or fetal status.
C. Naloxone hydrochloride: Naloxone is not a pain-management measure; it is an opioid antagonist used to reverse opioid-induced respiratory depression. It does not provide analgesia and is not administered for pain relief during labor.
D. Spinal anesthesia: Spinal anesthesia is typically administered prior to a planned cesarean birth or late in the first stage of labor. It is not appropriate once the client is fully dilated and actively pushing, as it could delay delivery and complicate maternal positioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Perform aerobic activities three times per week.": While exercise can be beneficial, excessive aerobic activity may worsen fatigue in clients with MS. Low-impact and well-paced exercise is more appropriate.
B. "Soak in a hot bath.": Heat can exacerbate symptoms in clients with MS by increasing nerve conduction issues, potentially leading to worsening fatigue or vision changes.
C. "Have your partner complete activities of daily living for you.": Encouraging dependence can contribute to decreased function and self-esteem. Clients should be supported to remain as independent as possible within their limits.
D. "Schedule rest periods during the day.": Fatigue is a common symptom of MS. Rest periods help conserve energy and prevent exacerbation of symptoms, promoting better overall functioning.
Correct Answer is B
Explanation
Rationale:
A. Change the drainage tubing every 48 hr: Closed wound drainage systems are designed to remain intact and sterile until removal. Routine replacement of tubing can introduce pathogens and is not recommended unless there is evidence of damage or contamination.
B. Observe for drainage flow through the tubing: Monitoring the flow and character of drainage ensures the system is functioning correctly and allows early detection of complications like blockage, dislodgment, or infection.
C. Remove the drain if output from the drain increases: An increase in drainage volume can signal active bleeding, infection, or poor wound healing. Instead of removing the drain, the nurse should notify the provider for further evaluation and guidance on next steps.
D. Irrigate the drain to maintain suction: Closed drainage systems like Jackson-Pratt or Hemovac are designed to maintain negative pressure without irrigation. Introducing fluid into the system can break the vacuum seal, reduce effectiveness, and increase the risk of infection.
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