After several hours of using imagery and music to promote comfort, the laboring client becomes discouraged and frustrated.

What action will the nurse take?

Continue these methods until they work again.

Choose an alternate method of comfort promotion.

Ask the support person to leave the room temporarily.

Tell the client she needs to relax more.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Continuing the same comfort methods that have become ineffective is unlikely to help the client and may increase frustration. Adaptation to the client’s changing needs is necessary for effective care.
Choice B rationale
Choosing an alternate method of comfort promotion is appropriate as it addresses the client's current needs and helps to alleviate frustration. Alternate methods might include massage, repositioning, or hydrotherapy.
Choice C rationale
Asking the support person to leave the room may not address the client's comfort needs and could decrease her emotional support, potentially increasing stress and frustration rather than providing relief.
Choice D rationale
Telling the client to relax more is not supportive and does not provide a new strategy to promote comfort. It may be dismissive and can increase the client’s frustration and anxiety during labor.

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Correct Answer is A

Explanation

Choice A rationale
Strong rectal pressure indicates advanced labor and potential imminent delivery, requiring immediate assessment of cervical dilation to ensure appropriate intervention and prevent complications.
Choice B rationale
Encouraging the patient to push without confirming cervical dilation could lead to cervical trauma or delivery complications if dilation is not complete, making this action inappropriate.
Choice C rationale
Notifying the MD without first assessing cervical dilation may cause unnecessary delay in intervention, potentially leading to complications during labor and delivery if the patient is fully dilated.
Choice D rationale
Offering the patient the bedpan when she feels strong rectal pressure can increase the risk of delivering the baby in an inappropriate setting, as the rectal pressure suggests imminent birth.

A. This ointment prevents the infant’s eyelids from sticking together and helps the infant see. B. This ophthalmic ointment prevents gonorrheal infection of the infant’s eyes, potentially acquired from the birth canal. C. Erythromycin prevents potentially harmful exudate from invading the tear ducts of the infant’s eyes, leading to dry eyes. D. Erythromycin ophthalmic ointment destroys an infectious exudate caused by Staphylococcus that could make the infant blind.

Correct Answer is B

Explanation

Choice A rationale
Erythromycin ophthalmic ointment does not prevent the infant's eyelids from sticking together; it is not its primary purpose and does not aid in vision enhancement.
Choice B rationale
Erythromycin ophthalmic ointment is used to prevent gonorrheal infection acquired during birth, protecting the infant’s eyes from potential infection that can cause blindness.
Choice C rationale
Erythromycin does not prevent exudate from invading the tear ducts, nor does it lead to dry eyes. Its primary function is antimicrobial.
Choice D rationale
Erythromycin ophthalmic ointment is not specific to Staphylococcus and does not directly destroy infectious exudate. It prevents infections like gonorrhea.

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After several hours of using imagery and music to promote comfort, the laboring client becomes discouraged and frustrated. What action will the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a laboring woman, G3 P2, who was examined 15 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states she is feeling strong pressure in her rectum and wants to move her bowels. Which of the following action should the nurse perform first?

Correct Answer is A

Explanation

A new father wants to know what medication was put into his infant’s eyes and why it is needed. How does the nurse explain the purpose of the erythromycin ophthalmic ointment?

Correct Answer is B

Explanation

A woman in labor has just received an epidural block. The most important nursing intervention is to:

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The nurse is aware that labor and birth will most likely proceed normally when the fetal position is:

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When discussing work and travel during pregnancy with a pregnant patient, nurses should instruct them that.

After several hours of using imagery and music to promote comfort, the laboring client becomes discouraged and frustrated.

What action will the nurse take?