The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief?
Changing positions in bed
frequently asking for ice chips
Taking deep breaths
Facial grimacing
The Correct Answer is D
A. Changing positions in bed: This may indicate discomfort but not necessarily pain.
B. Frequently asking for ice chips: Suggests thirst or distraction, not pain.
C. Taking deep breaths: Often part of coping strategies, not a direct indicator of unrelieved pain.
D. Facial grimacing: A non-verbal cue strongly associated with pain or discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An external fetal monitor will be used to monitor the FHR: Nonstress tests (NST) monitor the fetal heart rate (FHR) in response to fetal movements using external monitors.
B. The client will receive an ultrasound prior to the test: An ultrasound is not part of the standard procedure for an NST.
C. An IV will be initiated prior to the test: An IV is unnecessary; the test is noninvasive.
D. The client will be asked to stimulate her nipples for 5 min during the test: Nipple stimulation is part of a contraction stress test, not an NST.
Correct Answer is D
Explanation
A. Maternal fever: Fever is associated with fetal tachycardia, not variable decelerations.
B. Fetal head compression: This causes early decelerations, not variable decelerations.
C. Polyhydramnios: Excess amniotic fluid can cause complications but does not directly cause variable decelerations.
D. Umbilical cord compression: Variable decelerations are due to compression of the umbilical cord, which affects fetal oxygenation.
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