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 A

Explanation

A. Blurred vision can indicate a prenatal complication, such as preeclampsia, which is a serious condition that can develop in the later stages of pregnancy and requires immediate attention. Preeclampsia can lead to severe health issues for both the mother and baby.
B. Shortness of breath can be a normal part of late pregnancy due to the pressure on the diaphragm from the growing uterus. While it should be monitored, it is not specifically indicative of a complication compared to other symptoms.
C. Non-pitting ankle edema is common in the later stages of pregnancy and is not necessarily a sign of a complication on its own. It can occur due to the increased fluid volume and pressure from the uterus.
D. Leukorrhea, or increased vaginal discharge, is a common and normal finding in pregnancy, especially as labor approaches. It is generally not a sign of a complication unless accompanied by other concerning symptoms.

A. Uterine contractions lasting 30 to 45 seconds B. Uterine contractions every 6 min C. Recurrent variable deceleration of the FHR D. Moderate variability of the FHR

Correct Answer is C

Explanation

A. Uterine contractions lasting 30 to 45 seconds
Rationale: Uterine contractions lasting 30 to 45 seconds are within the expected range for the latent phase of labor. This duration indicates that contractions are occurring but are not too frequent or too prolonged, which is typical for this stage of labor.
B. Uterine contractions every 6 min
Rationale: Contractions every 6 minutes are also typical for the latent phase of labor, where contractions are still becoming more frequent as labor progresses. This frequency does not suggest fetal distress or a significant risk to the fetus.
C. Recurrent variable deceleration of the FHR
Rationale: Recurrent variable decelerations in fetal heart rate (FHR) indicate that the fetus might be experiencing umbilical cord compression. This finding suggests a risk to the fetus, as it can be associated with reduced oxygenation and may require intervention to manage labor and optimize fetal well-being.
D. Moderate variability of the FHR
Rationale: Moderate variability in FHR is an indication of a well-oxygenated fetus and a healthy autonomic nervous system. This is a reassuring sign of fetal well-being rather than a risk.

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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?

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Naxlex Comprehensive Predictor Exams

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