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A nurse is caring for a client who is reporting severe pain during labor and is no longer wanting to follow their natural birth plan. Which of the following interventions should the nurse recognize as being supportive and appropriate for the partner at the bedside to take?
Select all that Apply.

Playing soothing music

Helping with breathing techniques

Telling the client not to take any medication.

Giving a back massage

Helping the client concentrate on their focal point.

Answer and Explanation

Correct Answer : A,B,D,E

A. Playing soothing music: Promotes relaxation and distraction from pain.

B. Helping with breathing techniques: Encourages proper oxygenation and pain management.

C. Telling the client not to take any medication: This is not supportive; decisions about medication should respect the client’s wishes.

D. Giving a back massage: Relieves tension and provides comfort.

E. Helping the client concentrate on their focal point: Assists with distraction and relaxation during contractions.

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Correct Answer is A

Explanation

A. Stop the oxytocin infusion: Oxytocin should be stopped immediately to prevent hyperstimulation of the uterus, which can lead to fetal distress or uterine rupture.

B. Turn her on her left side and reassess the contractions: While this position can improve fetal oxygenation, it does not address the root cause, which is uterine hyperstimulation.

C. Continue the infusion and report the findings to the physician: Unsafe action as uterine hyperstimulation poses significant risks.

D. Administer oxygen by mask: Oxygen may be needed but is not the priority. Stopping the oxytocin is the first step.

A. Cover the cord with a sterile, moist saline dressing B. Explain to the client what is happening. C. Place the client in a knee-chest or Trendelenburg position. D. Prepare the client for an emergency cesarean birth.

Correct Answer is C

Explanation

A. Cover the cord with a sterile, moist saline dressing: While necessary to prevent cord drying, the first priority is to relieve pressure on the cord.

B. Explain to the client what is happening: Providing information is important but not the priority in an emergency.

C. Place the client in a knee-chest or Trendelenburg position: This action uses gravity to relieve pressure on the umbilical cord, promoting fetal oxygenation.

D. Prepare the client for an emergency cesarean birth: This is necessary but secondary to ensuring immediate cord decompression.

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A nurse is caring for a client who is reporting severe pain during labor and is no longer wanting to follow their natural birth plan. Which of the following interventions should the nurse recognize as being supportive and appropriate for the partner at the bedside to take? Select all that Apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurse's initial action?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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A nurse is caring for a client who is reporting severe pain during labor and is no longer wanting to follow their natural birth plan. Which of the following interventions should the nurse recognize as being supportive and appropriate for the partner at the bedside to take?
Select all that Apply.