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 D
Explanation
A. How long the patient states the contractions last: This measures contraction duration, not frequency.
B. The time between the end of one contraction and the beginning of the next: This measures the interval, not frequency.
C. The time between the beginning and the end of one contraction: This measures the contraction’s duration.
D. The time between the beginning of one contraction and the beginning of the next: This is the standard way to measure contraction frequency.
Correct Answer is A
Explanation
A. Ineffective coping related to inadequate preparation for labor: This addresses the client’s inability to manage labor effectively due to a lack of childbirth preparation, as evidenced by her emotional distress.
B. Pain related to uterine contractions: While pain is present, addressing ineffective coping takes precedence because it impacts how the client handles labor and her perception of pain.
C. Risk for injury related to lack of prenatal care: This is important but not immediately relevant to her current emotional state and pain management needs.
D. Knowledge deficit related to the birth experience: While true, the immediate priority is the client's emotional and coping response.
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