A practical nurse assists in caring for a client in labor and would like to provide an environment that will help decrease the client's pain.
Which of the following should the nurse include? (Select All that Apply.)
Calm in the client's room.
Maintain privacy.
Effective communication.
Continuity of care.
Making choices for the client.
Correct Answer : A,B,C,D
Choice A rationale
A calm environment in the client's room reduces sensory overstimulation and promotes relaxation. This physiological state minimizes sympathetic nervous system activation, thereby reducing the perception of pain and allowing the client to better cope with labor contractions through a less intense physiological response.
Choice B rationale
Maintaining privacy during labor provides the client with a sense of security and control, which can reduce anxiety and stress. Reduced anxiety can modulate pain perception by decreasing the release of stress hormones, allowing the client to focus on coping mechanisms and relaxation techniques.
Choice C rationale
Effective communication involves clear, empathetic, and supportive dialogue. This fosters trust and provides reassurance, which can significantly lower a client's anxiety levels. Reduced anxiety decreases sympathetic nervous system activation, thereby diminishing the physiological perception of pain and enhancing coping abilities.
Choice D rationale
Continuity of care, where the client interacts with familiar caregivers, builds rapport and trust. This consistent support reduces anxiety and allows the client to feel more comfortable and secure. Lower stress levels minimize the release of pain-potentiating neurochemicals, thereby decreasing the subjective experience of pain during labor.
Choice E rationale
Making choices for the client removes their autonomy and can increase feelings of helplessness and anxiety. This can heighten the perception of pain by activating the sympathetic nervous system and stress responses, counteracting efforts to create a supportive and pain-reducing environment during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Rho(D) immune globulin, also known as RhoGAM, is an immunoglobulin product administered to Rh-negative individuals to prevent isoimmunization. It works by binding to and neutralizing any fetal Rh-positive red blood cells that may enter the maternal circulation, thereby preventing the maternal immune system from recognizing these cells and forming anti-Rh antibodies.
Choice B rationale
This statement is incorrect. Rho(D) immune globulin does not destroy pre-formed Rh antibodies in a woman. Its mechanism of action is prophylactic, preventing the initial sensitization and antibody formation, rather than treating existing antibodies. Once antibodies are formed, RhoGAM is ineffective.
Choice C rationale
This statement is incorrect. Rho(D) immune globulin is administered to the Rh-negative mother, not the Rh-positive newborn. The purpose is to protect future Rh-positive fetuses from maternal Rh antibody attack, as maternal antibodies can cross the placenta and cause hemolytic disease of the newborn.
Choice D rationale
This statement is incorrect. Rho(D) immune globulin is administered to the Rh-negative mother to prevent her immune system from forming antibodies. It does not directly act on the newborn or prevent antibody formation within the newborn. The focus is on maternal sensitization.
Correct Answer is A
Explanation
Choice A rationale
Ensuring the car seat is securely installed and properly buckled is paramount for infant safety. Correct installation prevents excessive movement of the car seat during a collision, and proper buckling ensures the infant is restrained effectively, reducing the risk of ejection or injury from impact forces.
Choice B rationale
Using an expired car seat or one that has been involved in a previous accident is highly dangerous. Over time, materials degrade, and the structural integrity of a car seat can be compromised after an accident, even if there are no visible signs of damage. Expired seats may not meet current safety standards.
Choice C rationale
Always placing the car seat in the front seat, facing forward, is incorrect and extremely dangerous. The front passenger airbag can deploy with significant force, causing severe or fatal injuries to an infant in a car seat. Infants and young children should always be in the back seat to mitigate this risk.
Choice D rationale
Placing the car seat in the middle of the back seat, facing forward, is incorrect for infants. Infants should always be in a rear-facing car seat until they meet the maximum height or weight limits for their rear-facing car seat, typically around 2 years of age or older. The middle back seat is generally safest for placement due to optimal crash protection.
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