A nurse is contributing to the plan of care for a client who is in early labor and reports low-back pain during contractions. Which of the following interventions should the nurse include in the plan?
"Assist the client's partner to apply counterpressure to the sacrum."
"Teach the client to hold their breath during contractions."
"Maintain the client on bed rest until active labor begins."
"Insert an indwelling urinary catheter."
The Correct Answer is A
A. Counterpressure applied to the sacrum is effective for relieving low-back pain during labor. This technique can help alleviate discomfort associated with contractions and provide comfort to the laboring client.
B. Holding the breath during contractions is not recommended as it can decrease oxygen flow to the mother and baby. Breathing techniques that focus on relaxation and proper oxygenation are preferred.
C. Bed rest is not necessary for a client in early labor and can be counterproductive. Allowing the client to move and find comfortable positions is more beneficial during early labor.
D. An indwelling urinary catheter is not required in early labor unless there is a specific medical reason. Routine catheterization is not a standard part of early labor management.
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Related Questions
Correct Answer is B
Explanation
A. Insert the suppository 5 cm (2 in) is incorrect. The suppository should be inserted about 2-3 inches into the vaginal canal, not specifically 5 cm, but the exact depth may vary.
B. Insert the suppository along the posterior vaginal wall is correct. Inserting the suppository along the posterior vaginal wall helps ensure it reaches the area where it is needed for effective treatment.
C. Apply petroleum jelly to the suppository is incorrect. The suppository should not be coated with petroleum jelly; it should be used as is to avoid interference with its absorption and effectiveness.
D. Assist the client into a prone position is incorrect. The client should be assisted into a supine position with knees bent or into a lithotomy position for the insertion of the suppository, not a prone position.
Correct Answer is C
Explanation
A. A Mongolian spot is a benign, pigmented skin mark common in newborns, particularly those with darker skin. It is not related to rubella exposure during pregnancy.
B. Jaundice in the newborn can be a common finding and is not specifically related to maternal rubella exposure. Jaundice often resolves with time or may require treatment, but it is not a direct consequence of rubella.
C. Deafness is a known congenital defect associated with rubella syndrome. Infants exposed to rubella during pregnancy are at risk for serious outcomes, including hearing impairments.
D. Transient strabismus is a common condition in newborns and is not specifically associated with maternal rubella exposure. It typically resolves as the baby grows.
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