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 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. .
Correct Answer is D
Explanation
Choice A rationale
A guardian's statement that a child fell off a swing is a common and plausible explanation for a fractured arm. This type of injury is consistent with the normal activities of a preschooler, and it does not inherently suggest abuse. The nurse should continue with a thorough physical assessment and gather additional history, but this statement alone is not a red flag.
Choice B rationale
Crying loudly when a fractured arm is moved is a normal, expected reaction to pain. The child is experiencing acute pain from the injury, and any movement of the affected limb would cause a significant increase in discomfort. This is not a warning sign of maltreatment but rather a natural physiological response to a painful stimulus.
Choice C rationale
A guardian wanting to accompany a child to the radiology department is a typical and often protective behavior. Many parents wish to provide emotional support to their child during stressful medical procedures. This action demonstrates parental involvement and concern for the child's well-being and is not indicative of abuse or neglect.
Choice D rationale
A delay in seeking medical care for a significant injury, such as a fractured arm, is a major red flag for child maltreatment. This delay suggests that the guardian may be attempting to hide the cause of the injury or is neglectful of the child's health needs. Timely medical attention for a painful injury is the standard of care. .
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