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."

Answer and Explanation

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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Correct Answer is D

Explanation

A. Leukorrhea, a normal increase in vaginal discharge, is a common and expected finding during pregnancy. It usually does not require immediate medical intervention unless accompanied by other symptoms.
B. Gingivitis is a common issue during pregnancy due to hormonal changes, but it is generally managed with good oral hygiene and routine dental care. It is not an urgent finding compared to other conditions.
C. Varicose veins are a common condition during pregnancy due to increased blood volume and pressure on the veins. While they can be uncomfortable, they are generally managed through lifestyle changes and do not represent an immediate risk.
D. Dysuria, or painful urination, may indicate a urinary tract infection or another serious condition that requires prompt medical attention. It can lead to complications if untreated, so it is a priority finding that needs to be reported to the provider for further evaluation and treatment.

A. A client whose newborn is having difficulty latching-on B. A client who received magnesium sulfate during labor C. A client who has a history of oligohydramnios D. A client whose labor lasted for 6 hr

Correct Answer is B

Explanation

A. A client whose newborn is having difficulty latching-on should be addressed, but this issue is not an immediate postpartum emergency. It is important but does not require urgent intervention compared to potential complications from magnesium sulfate.
B. A client who received magnesium sulfate during labor should be seen first because magnesium sulfate can cause significant side effects like respiratory depression, decreased reflexes, and altered mental status. These effects require close monitoring to prevent severe complications.
C. A client who has a history of oligohydramnios requires monitoring but this history does not necessarily indicate an immediate postpartum issue requiring urgent assessment at this time.
D. A client whose labor lasted for 6 hr does not have an immediate concern solely based on labor duration. While it is relevant, it does not indicate an urgent need for assessment compared to the effects of magnesium sulfate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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