A practical nurse is gathering data on a laboring client's perception of pain. Which of the following should be included? (Select All that Apply.)
The quality of the pain
The client's allergies
The location of the pain
The intensity of the pain
The client's family history of pain
The client's blood pressure
Correct Answer : A,C,D
A. The quality of the pain – Correct; describes how the pain feels (e.g., sharp, dull, cramping).
B. The client's allergies – Incorrect; allergies are important for medication safety, but they do not assess pain perception.
C. The location of the pain – Correct; helps determine if the pain is contraction-related or another issue.
D. The intensity of the pain – Correct; measured using a pain scale.
E. The client's family history of pain – Incorrect; individual perception of pain is more relevant than family history.
F. The client's blood pressure – Incorrect; BP is monitored in labor but is not part of pain perception assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The contractions are regular – Incorrect; regular contractions occur throughout labor, not just in the second stage.
B. The cervix is fully dilated. – Correct; the second stage of labor begins when the cervix is completely dilated (10 cm), allowing for pushing and delivery.
C. The membranes have ruptured – Incorrect; rupture of membranes can occur at any stage of labor.
D. The provider has ruptured the membranes – Incorrect; artificial rupture (amniotomy) does not determine the start of the second stage.
Correct Answer is D
Explanation
A. Hypnosis, imagery, and slow chest breathing – Incorrect; while these techniques can help with general labor pain, they may not be effective for severe back pain due to fetal positioning.
B. Comfort measures, intermittent labor support by the nurse, and reassurance that the pain is temporary – Incorrect; while support is important, it does not directly relieve back pain.
C. Effleurage, ambulation, and frequent position changes – Incorrect; these may help, but they do not directly address back labor.
D. Counterpressure with a fist or tennis ball to the lower back – Correct; back labor is often caused by occiput posterior fetal positioning, and counterpressure helps relieve pain by applying direct pressure to the sacrum.
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