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A nurse is developing a plan of care for a client who is in the latent phase of labor.Which of the following interventions should the nurse include in the plan to manage the client's pain?

Encourage the client to listen to music.

Instruct the client on how to use biofeedback.

Administer fentanyl 100 mg every hour via intermittent bolus.

Request the provider to administer a pudendal nerve block.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Music can be a non-pharmacological method to help manage pain and anxiety during the latent phase of labor.

Choice B rationale

Biofeedback might be helpful but can be challenging to implement without prior training.

Choice C rationale

Administering fentanyl 100 mg every hour is not appropriate; fentanyl is typically administered in much smaller doses.

Choice D rationale

A pudendal nerve block is usually reserved for the second stage of labor or delivery, not the latent phase.

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Correct Answer is A

Explanation

Choice A rationale

Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.

Choice B rationale

Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.

Choice C rationale

Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.

Choice D rationale

Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.

A. I should see my provider in 2 weeks for a second dose of the immunization. B. I need to prevent getting pregnant for 4 months after I receive the immunization. C. I will need an additional rubella immunization during the first trimester of my next pregnancy. D. I can breastfeed my baby even though I received this immunization.

Correct Answer is D

Explanation

Choice A rationale

Only one dose of rubella immunization is necessary post-delivery, no need for a second dose in 2 weeks.

Choice B rationale

Prevention of pregnancy is recommended for at least 1 month (not 4 months) after receiving the rubella vaccine to avoid possible teratogenic effects.

Choice C rationale

An additional rubella immunization is not recommended during pregnancy as the live vaccine is contraindicated during gestation.

Choice D rationale

Rubella vaccine is safe for breastfeeding mothers, as it does not affect the safety of breast milk.

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A nurse is developing a plan of care for a client who is in the latent phase of labor.Which of the following interventions should the nurse include in the plan to manage the client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is in active labor is admitted to a labor and delivery unit reporting "My water just broke and my baby is breech.”. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is assessing a newborn who is breastfed and has a weight loss of 11% at 48 hr after birth.Which of the following findings should the nurse report to the provider?

A nurse is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum.Which of the following are findings of this condition? (Select all that apply.)

A nurse is providing client teaching regarding an intrauterine device (IUD). Which of the following statements should the nurse include in the teaching? (Select all that apply.)

A nurse is completing a health history and assessment for a client who reports they are pregnant.Which of the following findings is a presumptive sign of pregnancy?

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation and has a history of anemia.Which of the following results should the nurse identify and report as an indication of a prenatal complication?

A nurse is caring for a postpartum client who is breastfeeding their newborn and reports that their nipples have become sore and cracked.Which of the following statements should the nurse make?

A nurse is preparing to administer an opioid analgesic to a client who is in active labor.Which of the following assessments should the nurse perform? (Select all that apply.)