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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

Answer and Explanation

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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Correct Answer is C

Explanation

A. "I should monitor my weight gain during the following months." – Correct; gradual and appropriate weight gain is essential for maternal and fetal health.

B. "I will consult with my doctor before using home remedies for nausea." – Correct; some herbal remedies and over-the-counter treatments can be harmful during pregnancy.

C. "I will use only nonprescription medications while pregnant." – Incorrect; even nonprescription medications can be harmful, and pregnant clients should consult their provider before using any medication.

D. "I am going to reduce my stress level." – Correct; stress management is beneficial during pregnancy.

A. Notify social services. B. Ask the parents what caused the bruises. C. Ask the toddler what caused the bruises. D. Notify the provider.

Correct Answer is B

Explanation

A. Notify social services. – Incorrect; while reporting may be necessary, the nurse must first gather more information.

B. Ask the parents what caused the bruises. – Correct; the nurse should first assess by asking the parents in a nonjudgmental manner to determine if the bruises are accidental or suspicious for abuse.

C. Ask the toddler what caused the bruises. – Incorrect; toddlers may have limited verbal skills, and their responses may not be reliable.

D. Notify the provider. – Incorrect; while the provider should be informed, the nurse must first assess before escalating concerns.

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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.)

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