A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
Assist the client with breathing and imagery techniques in an attempt to calm her down.
Ask the client to describe the intensity of her pain on a scale of 0 to 10.
Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication.
Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk.
The Correct Answer is A
Choice A reason:
This is the best response because it shows that the nurse is providing nonpharmacological pain relief measures and supporting the client's coping mechanisms. Breathing and imagery techniques can help the client relax and focus on something other than the pain. Moaning, screaming, and vocalizing are normal and acceptable ways of expressing pain during labor, and the nurse should not try to suppress them.
Choice B reason:
This is not the best response because it does not address the husband's concern or offer any intervention for the client's pain. Asking the client to rate her pain on a scale of 0 to 10 is a subjective assessment tool that may not reflect the true intensity of her pain. Furthermore, it may be difficult for the client to answer this question while she is in the second stage of labor.
Choice C reason:
This is not the best response because it may not be feasible or appropriate to administer more pain medication to the client in the second stage of labor. The obstetrician may not be available to evaluate the client's pain, and increasing the dose of pain medication may have adverse effects on the client and the fetus, such as respiratory depression, hypotension, and decreased uterine contractility.
Choice D reason:
This is not the best response because it does not acknowledge the husband's feelings or provide any comfort or education for him. Reassuring him that his wife will be fine may sound dismissive and insensitive, and offering to stay with her while he takes a walk may imply that he is not needed or wanted in the birthing room. The nurse should involve the husband in the care of his wife and explain to him what is happening and what to expect during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
10% to 15% of their birth weight. This is incorrect because this range is too high for a normal newborn weight loss. Losing more than 10% of their birth weight may indicate dehydration, inadequate feeding, or other problems. • Choice B reason:
20% of their birth weight. This is incorrect because this percentage is way too high for a normal newborn weight loss. Losing 20% of their birth weight would be a serious sign of illness or malnutrition. • Choice C reason:
15% to 18% of their birth weight. This is incorrect because this range is also too high for a normal newborn weight loss. Losing 15% to 18% of their birth weight would be a cause for concern and require further evaluation. • Choice D reason:
5% to 10% of their birth weight. This is correct because this range is within the normal limits for a newborn weight loss. Newborns lose some weight as a result of insufficient caloric intake, fluid loss, and metabolic adjustments in the first week after birth. They usually regain their birth weight by the second week.
Correct Answer is C
Explanation
Choice A reason:
Rupture of the membranes is not a reliable sign of true labor, as it can occur before or during labor, or be artificially induced by the provider. • Choice B reason:
Patterns of contractions can vary depending on the stage and phase of labor, and can also be influenced by factors such as hydration, activity, and medication. Contractions alone do not indicate true labor unless they are accompanied by cervical changes. • Choice C reason:
Changes in the cervix, such as effacement (thinning) and dilation (opening), are the most accurate indication of true labor. Cervical changes are caused by the pressure of the presenting part and the force of the contractions. The nurse should assess the cervix periodically to determine the progress of labor. • Choice D reason:
The station of the presenting part refers to the relationship of the fetal head to the maternal ischial spines, which are bony landmarks in the pelvis. The station can range from -5 (high) to +5 (low), with 0 being at the level of the ischial spines. Station does not indicate true labor, as it can vary depending on the parity, pelvic shape, and fetal position of the client.
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