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A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain.
Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.)

Perform Leopold maneuvers.

Apply counterpressure to the sacral area

Ambulate the client in the hallway

Administer 70-90% nitrous oxide mixed with oxygen

Answer and Explanation

Correct Answer : B,C,D,E

Applying counterpressure to the sacral area can help alleviate back pain during labor.

Ambulating the client in the hallway can help with pain management and facilitate labor progress.

Administering nitrous oxide mixed with oxygen can provide pain relief during labor.

Having the client sit upright can help with pain management and facilitate labor progress.

Choice A is incorrect because performing Leopold maneuvers is a technique used to assess fetal position and presentation and is not a pain management technique.

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Correct Answer is C

Explanation

Rubella vaccine is a live atenuated vaccine and women should avoid pregnancy for at least 28 days after receiving the vaccine.

Choice A is incorrect because the rubella vaccine is given as a single dose, not a series of three immunizations.
Choice B is incorrect because joint pain is a common side eﬀect of the rubella vaccine and does not need to be reported immediately to the provider.
Choice D is incorrect because breastfeeding is not contraindicated following rubella immunization.

A. The client has non-pitting pedal edema. B. The client has a fundal height of 38 cm. C. The client reports 12 fetal movements in hr. D. The client has a fasting blood glucose of 90 mg/du.

Correct Answer is B

Explanation

The nurse should report a fundal height of 38 cm to the provider.

Fundal height is measured from the top of the pubic bone to the top of the uterus and is used to assess fetal growth.
A fundal height measurement that is larger than expected for gestational age may indicate macrosomia, which is a common complication of gestational diabetes mellitus.
Choice A is incorrect because non-pitting pedal edema is common during late pregnancy and is usually caused by physiologic edema resulting from hormone- induced sodium retention.
Choice C is incorrect because 12 fetal movements in an hour are within normal
range.
Choice D is incorrect because a fasting blood glucose level of 90 mg/dL is within normal range for a pregnant woman with gestational diabetes mellitus.

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A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain. Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.)

Nursing Test Bank

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A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

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Correct Answer is B

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A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain.
Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.)