A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station.
Which of the following interventions should the nurse implement?
Apply counterpressure during each contraction.
Administer a dose of terbutaline to the client.
Request the provider prescribe a pudendal nerve block.
Place the client in a warm bath.
The Correct Answer is A
Choice A rationale
Counterpressure is a nonpharmacologic pain management technique that involves applying firm, steady pressure to the sacral area during contractions. It is particularly effective for back pain during labor, which is often caused by the occiput of the fetus pressing against the maternal sacrum. This physical pressure helps to distract the brain from the pain signals and can help to realign the fetal head. It provides direct relief by counteracting the pressure from the fetus.
Choice B rationale
Terbutaline is a tocolytic medication that is used to relax the smooth muscles of the uterus and inhibit contractions. Administering this medication would halt the progression of labor, which is not the goal in this situation. The client is in the latent phase of labor, and the primary goal is to manage the pain while allowing the labor process to continue naturally. Therefore, terbutaline is contraindicated as it would interfere with the normal course of labor.
Choice C rationale
A pudendal nerve block is a form of regional anesthesia that anesthetizes the pudendal nerve, providing pain relief to the perineum, vulva, and vagina. It is typically administered in the second stage of labor just before delivery or for an episiotomy repair, as it is not effective for the pain associated with uterine contractions. The client is in the latent phase of labor and experiencing back pain, so a pudendal block would not be an appropriate intervention at this time.
Choice D rationale
While a warm bath can be a useful comfort measure during labor, it is not the most effective intervention for severe back pain specifically caused by the fetal position. Counterpressure provides targeted, direct pressure to the source of the pain, offering more immediate and substantial relief. A warm bath may provide general relaxation and distraction, but it does not address the underlying mechanical cause of the pain as effectively as counterpressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Looping the tubing so it is lower than the collection bag creates a dependent loop, which can cause urine to pool and create a backflow into the bladder. This stasis of urine provides a fertile environment for bacteria to multiply and ascend the urinary tract, significantly increasing the client's risk for a urinary tract infection. The bag should always be below the bladder.
Choice B rationale
Keeping the urinary bag at bladder level or higher when ambulating is a significant risk factor for urinary tract infections. This positioning allows for the backflow of urine from the collection bag into the bladder. The retrograde flow of urine can transport bacteria into the sterile bladder, leading to bacterial colonization and a subsequent infection.
Choice C rationale
Securing the catheter to the client's thigh is a crucial intervention for minimizing the risk of a UTI. It prevents movement and traction on the catheter at the urethral meatus. This minimizes urethral tissue irritation and micro-trauma, which can serve as entry points for bacteria. It also reduces tension on the catheter, preventing accidental dislodgement.
Choice D rationale
Disconnecting the tubing connections to obtain a urinary sample is a high-risk action for introducing microorganisms. Each disconnection breaks the closed, sterile system, allowing airborne bacteria or contaminants from the external environment to enter the catheter and tubing. This breach of sterility can lead to bacterial ascension into the bladder, causing a urinary tract infection. *.
Correct Answer is A
Explanation
Choice A rationale
Spina bifida is associated with a high incidence of latex allergy due to repeated surgical procedures and catheterizations. There is a documented cross-reactivity between latex proteins and certain food proteins, particularly those found in bananas, avocados, kiwis, and chestnuts. These foods share similar antigenic determinants.
Choice B rationale
Strawberries are not typically associated with latex cross-reactivity. While they can cause allergic reactions in some individuals, the proteins responsible for these allergies do not share the same antigenic structures as those found in natural rubber latex. Therefore, a latex allergy does not necessarily predict a strawberry allergy.
Choice C rationale
Almonds are a tree nut, and while tree nut allergies are common, they are not typically linked to latex cross-reactivity. The allergenic proteins in almonds, such as the major protein Amandin, are structurally different from the proteins found in natural rubber latex, minimizing the risk of a cross-reaction.
Choice D rationale
Hazelnuts, like almonds, are a type of tree nut and are not generally known for cross-reactivity with latex. The proteins that trigger hazelnut allergies do not share significant homology with the proteins in natural rubber latex, so there is no established correlation between a latex allergy and a hazelnut allergy. .
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