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A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
- A. Administer prescribed analgesic medication.
- B. Encourage the client to rest between contractions.
- C. Massage the client's back.
- D. Turn the client onto her left side.
Correct Answer: C
Rationale: The gate control theory of pain proposes that non-painful input can close the "gates" to painful input, which helps to control and reduce pain perception. Massage, such as massaging the client's back, is a non-pharmacological intervention that can help close the gates and reduce the perception of pain. By massaging the client's back, the nurse is applying this theory to help manage the client's labor pain. Administering analgesic medication (Choice A) is a pharmacological intervention and not specifically related to the gate control theory. Choices B and D are also beneficial nursing actions but do not directly relate to the gate control theory of pain.
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The nurse is preparing a client for a nonstress test. What instruction is most appropriate?
- A. You need to fast for 12 hours before the test.
- B. You will be given medication to stimulate fetal movements.
- C. You will need to press a button each time you feel the baby move.
- D. You must lie flat on your back during the test.
Correct Answer: C
Rationale: The client presses a button during fetal movements, which are correlated with fetal heart rate changes.
A client at 34 weeks' gestation is diagnosed with polyhydramnios. What is the nurse's priority assessment?
- A. Monitor maternal blood pressure.
- B. Assess for signs of preterm labor.
- C. Check for signs of infection.
- D. Evaluate for fetal heart rate changes.
Correct Answer: B
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension, requiring close monitoring.
the nurse knows that management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides are for a client with this condition should be aware that which of the following is the optimal pharmacological therapy for pain relief dysmenorrhea? Management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides care for a client with this condition should be aware that the optimal pharmacologic therapy for pain relief is:
- A. Acetaminophen.
- B. Oral contraceptives (OCPs). c.Nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Aspirin
- D. ampicillin
Correct Answer: C
Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered the optimal pharmacological therapy for pain relief in primary dysmenorrhea. They work by reducing the production of prostaglandins, which are responsible for causing uterine contractions and pain. NSAIDs such as ibuprofen, naproxen, and mefenamic acid are commonly used to alleviate menstrual cramps. Acetaminophen may also provide pain relief, but it does not have the anti-inflammatory properties of NSAIDs. Oral contraceptives (OCPs) can help regulate menstrual cycles and reduce pain in some individuals, but they are not the first line of treatment for immediate pain relief in primary dysmenorrhea. Aspirin, while an NSAID, is not typically recommended for menstrual pain relief due to its potential side effects on blood clotting and gastrointestinal irritation.
The nurse is caring for a postpartum client who is
- A. Maternal hyperglycemia 1 day postcesarean birth. What assessment data
- B. FHR, early decelerations would indicate infection? Select all that apply.
- C. FHR, late decelerations
- D. Increased pulse
Correct Answer: A
Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate
- D. variability Fetal heart rate of 118/min
Correct Answer: B
Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.