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 C

Explanation

A. Experiencing burning during urination is not a normal physiological change during pregnancy and could indicate a urinary tract infection. It is important to report this symptom to a healthcare provider for evaluation and appropriate management.
B. The dark line in the middle of the abdomen, known as the linea nigra, is a common and normal physiological change during pregnancy due to hormonal effects, not an indication of infection. This statement reflects a misunderstanding of normal pregnancy changes.
C. Developing discoloration on the cheeks, often referred to as the "mask of pregnancy" or melasma, is a common and expected physiological change due to hormonal fluctuations. This statement shows that the client understands a normal aspect of pregnancy.
D. Swelling of the fingers and face is not a typical or expected change during pregnancy and could indicate a serious condition such as preeclampsia. While mild swelling of the ankles and feet can be normal, swelling in these areas should be evaluated by a healthcare provider.

A. "Asymptomatic palpitations" B. "Abdominal cramping" C. "Bleeding gums" D. "White vaginal discharge"

Correct Answer is B

Explanation

A. Asymptomatic palpitations are generally not a concern during pregnancy. They can be a common and benign experience due to increased blood volume and changes in heart function.
B. Abdominal cramping at 26 weeks of gestation may indicate preterm labor or other complications and should be reported to the provider. Persistent or severe cramping can be a sign of potential issues requiring medical evaluation.
C. Bleeding gums are common due to increased blood flow and hormonal changes in pregnancy. This symptom is usually not serious but should still be monitored.
D. White vaginal discharge is normal during pregnancy and often increases as pregnancy progresses. It is usually not a sign of a problem unless accompanied by other symptoms.
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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

A nurse in a prenatal clinic is reinforcing teaching with a client about expected physiological changes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse in a prenatal clinic is collecting data from a client who is at 26 weeks of gestation. Which of the following findings reported by the client should the nurse report to the provider?

Correct Answer is B

Explanation

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