A patient in the latent phase of labor begins to experience nausea, feelings of helplessness and has become very irritable. The nurse suspects that the patient is now in the

Not satisfied with the nonpharmacological comfort measures

active phase of labor

Going to require more pain medication

Going to have a long labor

Answer and Explanation

The Correct Answer is B

A. Not satisfied with the nonpharmacological comfort measures. This describes dissatisfaction with pain management but does not specifically indicate a change in labor phase.

B. Active phase of labor. Nausea, irritability, and feelings of helplessness are classic signs of transitioning from the latent phase to the active phase of labor, when contractions become stronger and more intense.

C. Going to require more pain medication: Although the patient may need additional pain relief, the question is asking about labor progression, not pain management.

D. Going to have a long labor. Irritability and nausea are signs of labor progression, not necessarily an indicator of a long labor.

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Correct Answer is ["A","B","D"]

Explanation

A. Create a warm relaxing environment: A warm and relaxing environment can help reduce stress and anxiety, contributing to pain relief during labor.

B. Administering sacral counterpressure: Sacral counterpressure, where pressure is applied to the lower back, is a non-pharmacological method used to relieve labor pain, particularly during back labor.

C. Epidural injection: An epidural injection is a pharmacological pain management technique, as it involves the administration of anesthetic drugs.

D. Effleurage: Effleurage is a light, circular massage technique that helps distract the mother from contraction pain, making it a non-pharmacological pain relief method.

A. Take the client's temperature. B. Check the fetal heart rate pattern. C. Observe the color and consistency of amniotic fluid. D. Evaluate the client for signs of infection.

Correct Answer is B

Explanation

A. Take the client's temperature. Monitoring the client's temperature for signs of infection is important, but it is not the priority immediately following an amniotomy. Infection typically develops over time.

B. Check the fetal heart rate pattern. The priority after an amniotomy is to assess the fetal heart rate to detect any signs of umbilical cord prolapse or fetal distress, which can occur immediately after rupture of membranes.

C. Observe the color and consistency of amniotic fluid. Although it is important to observe amniotic fluid for abnormalities (e.g., meconium staining), the immediate priority is fetal heart rate monitoring.

D. Evaluate the client for signs of infection. Signs of infection should be monitored, but they are not the priority right after amniotomy.

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A patient in the latent phase of labor begins to experience nausea, feelings of helplessness and has become very irritable. The nurse suspects that the patient is now in the

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is considered non-pharmacological pain management from the list below? (please select all that apply)

Correct Answer is ["A","B","D"]

Explanation

A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

Correct Answer is B

Explanation

During the active phase of labor, which of the following is a common sign that indicates progress?

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?

A patient in the latent phase of labor begins to experience nausea, feelings of helplessness and has become very irritable. The nurse suspects that the patient is now in the

A nurse is reinforcing teaching with a client who is in labor about an episiotomy. Which of the following information should the nurse include?

What is the most common cause of early decelerations in fetal heart rate?

A disadvantage of internal fetal monitoring is:

A nurse is assisting with the care of a client in active labor. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?