A nurse is caring for a client who is in the first stage of labor.
The client is stating that her pain level is 8/10 during her contractions but does not want an epidural.
The nurse assists with a position change and offers Fentanyl for pain relief.
The client requests the offered pain medication.
What action should the nurse perform first?
Provide ice chips or mouth swabs.
Assess and document maternal vital signs and fetal heart rate after medication.
Dim the lights and provide a quiet atmosphere.
Assist the patient with coping skills including breathing techniques.
The Correct Answer is B
Choice A rationale
Providing ice chips or mouth swabs can help keep the client comfortable and hydrated, but it is not the priority action when administering pain medication.
Choice B rationale
Assessing and documenting maternal vital signs and fetal heart rate after administering Fentanyl is crucial. This ensures that the medication is not causing any adverse effects on the mother or fetus and that both are stable.
Choice C rationale
Dimming the lights and providing a quiet atmosphere can help create a calming environment, but it is not the priority action when administering pain medication.
Choice D rationale
Assisting the patient with coping skills, including breathing techniques, is important for managing pain, but it is not the priority action when administering pain medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The occiput anterior (OA) position is considered the optimal fetal position for vaginal birth. In this position, the baby’s head is down, and the back of the head (occiput) is facing the mother’s front. This position allows for the most efficient passage through the birth canal.
Choice B rationale
The occiput posterior (OP) position, where the baby’s head is down but facing the mother’s back, can lead to a longer and more painful labor. It is not considered optimal for vaginal birth.
Choice C rationale
Breech positions, where the baby’s buttocks or feet are positioned to come out first, are not optimal for vaginal birth and often require a cesarean section due to the increased risk of complications.
Choice D rationale
The transverse position, where the baby is lying sideways across the uterus, is not suitable for vaginal birth. This position typically requires a cesarean section to safely deliver the baby.
Correct Answer is B
Explanation
Choice A rationale
Category I tracings are normal and indicate no fetal hypoxia or acidemia. They include a baseline heart rate of 110-160 bpm, moderate variability, and no late or variable decelerations.
Choice B rationale
Category II tracings are indeterminate and include any of the following: baseline heart rate changes, minimal or marked variability, absence of accelerations, or periodic decelerations. A baseline heart rate of 175 bpm with moderate variability and absent accelerations fits this category.
Choice C rationale
Category III tracings are abnormal and indicate possible fetal hypoxia or acidemia. They include absent variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern.
Choice D rationale
Category IV is not a standard classification in fetal heart rate monitoring. The correct categories are I, II, and III6.
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