A term multigravida, who is receiving oxytocin IV for labor augmentation, is requesting pain medication. Review of the client's record indicates that she was medicated 30 minutes ago with butorphanol 2 mg and promethazine 25 mg IV push. Vaginal examination reveals that the client's cervical dilation is 3 cm, 10% eﬀaced, and at a 0 station. Which action should the practical nurse (PN) implement?

Coach the client to take slow, deep breaths during each contraction.

Report to the nurse that the client needs another dose of butorphanol.

Notify the healthcare provider.

Discontinue the oxytocin infusion.

Answer and Explanation

The Correct Answer is A

In this situation, the practical nurse (PN) should coach the client to take slow, deep breaths during each contraction. The client has already been medicated with butorphanol and promethazine for pain relief and it may not be appropriate to administer another dose at this time. Instead, the PN can provide non- pharmacological pain relief measures such as coaching the client to use breathing techniques to help manage the pain during contractions. The other actions listed may also be appropriate in some situations, but coaching the client to use breathing techniques is the most appropriate action in this situation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Encouraging the client to initiate daily rituals, such as practicing relaxation techniques, engaging in physical exercise, and spending time with friends and family, can be an eﬀective way to diminish anxiety. These activities can provide a sense of structure and routine that can help to manage stress and anxiety. Options A and C are not recommended because alcohol and caﬀeine can worsen sleeplessness and anxiety. Option B can be counterproductive and increase the client's anxiety level. Therefore, Option D is the best option to assist this client in diminishing his anxiety.

Therefore, options A, B, and C are not answers because they are not the best action to assist this client in diminishing his anxiety.

A. The newborn is infected with an infectious blood-borne disease. B. The mother no longer needs Rho (D) immune globulin injections. C. The mother's Rh antibodies are present in the neonatal serum. D. The newborn needs phototherapy for physiologic jaundice.

Correct Answer is C

Explanation

A positive indirect Coombs' test indicates that the mother has developed Rh antibodies against the baby's Rh-positive blood. This finding can result in hemolytic disease of the newborn, which is a condition in which the mother's Rh antibodies atack the baby's red blood cells, causing destruction and potential anemia.

The baby may require phototherapy for physiologic jaundice, but the Coombs' test result indicates a diﬀerent issue.

The presence of an infectious blood-borne disease cannot be determined from this test.

The mother may still need Rho (D) immune globulin injections after delivery of an Rh-positive baby.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A highly successful businessman presents to a mental health center complaining of sleeplessness and anxiety over his financial status. Which action should the practical nurse (PN) take to assist this client in diminishing his anxiety?

Correct Answer is D

Explanation

A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs' test. What is the implication of this finding?

Correct Answer is C

Explanation

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the practical nurse (PN) to ask?

Epidural anesthesia is initiated for a primigravida at 40 weeks gestation who is in active labor. Which assessment has the greatest priority for the practical nurse to monitor during the administration of epidural anesthesia?

Which information is most important for the practical nurse (PN) to relay to the registered nurse (RN) concerning a 24-hour-old infant?

The practical nurse (PN) is assigned to assist in the care of a client at 34-weeks gestation with premature rupture of membranes (PROM). Four hours after admission, the PN recognizes an increasing trend in the maternal heart rate. Which action should the PN take?

The practical nurse (PN) is preparing a client at 22-weeks gestation for an amniocentesis. Which instruction should the PN give to this client?

The mother of a child who is hospitalized with croup and is in a mist tent brings the child's favorite stuﬀed animal to the hospital. Which action should the practical nurse (PN) take?