Nokea
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage
- B. Apply counter pressure to the client sacral.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: In the transition phase of labor, the contractions are intense and the client may experience significant discomfort and pain. Applying counter pressure to the client's sacral area can help alleviate this pain by providing some relief and support. Counter pressure involves applying firm pressure with the palms or fists to the lower back or sacral area during contractions. This technique can help to relieve some of the pressure and discomfort experienced during contractions, making it a beneficial action for the nurse to take in this situation.
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The nurse is assessing a client who reports vaginal bleeding at 20 weeks' gestation. What is the priority action?
- A. Assess the amount and color of bleeding.
- B. Place the client in a Trendelenburg position.
- C. Administer Rho(D) immune globulin.
- D. Perform a vaginal examination.
Correct Answer: A
Rationale: Assessing the bleeding provides critical information to determine the next steps and evaluate potential complications.
What is the theory that supports HypnoBirthing?
- A. the fear-tension-pain theory
- B. the theory that pain is productive in labor
- C. the idea that self-hypnosis always works if you try hard enough
- D. the theory that when hypnotized during labor, the environment does not matter because the person is not aware of the surroundings
Correct Answer: A
Rationale: HypnoBirthing is based on the fear-tension-pain theory, which links fear to increased tension and pain.
A patient's newborn is neurologically impaired. The most important nursing action should be:
- A. Assist the patient and her family with the grieving process.
- B. Perform neurological assessments of the newborn every four hours.
- C. Arrange for social services to discuss possible placement of the newborn
- D. Obtain an order for an antidepressant to help the patient cope with the depressing news.
Correct Answer: A
Rationale: The most important nursing action when a patient's newborn is neurologically impaired is to assist the patient and her family with the grieving process. This situation can be extremely emotionally challenging for the parents and family as they come to terms with the newborn's condition. Providing support, empathy, and resources for coping with the grief is essential in helping the family navigate this difficult time. By being present, listening, and offering comfort, the nurse can help the family process their emotions and begin to cope with the situation. This support is crucial in promoting the overall well-being of the family as they adjust to the new reality of caring for a neurologically impaired newborn.
The nurse is caring for a client in the second stage of labor. What assessment indicates that birth is imminent?
- A. Cervix is dilated to 8 cm.
- B. Fetal head is crowning.
- C. Contractions every 3–5 minutes.
- D. Client reports back pain.
Correct Answer: B
Rationale: Crowning occurs when the fetal head becomes visible at the vaginal opening, indicating that birth is imminent.
Which of the following serve as maternal risk factors juice to having a baby who may suffer from birth trauma?
- A. Take her supplement after a meal Select all that apply.
- B. Take her supplement with full glass of tea
- C. Term delivery
- D. Scheduled cesarean delivery
Correct Answer: D
Rationale: Scheduled cesarean delivery serves as a maternal risk factor juice to having a baby who may suffer from birth trauma. Cesarean deliveries, especially scheduled ones without a medical indication, can increase the risk of birth trauma for the baby compared to a vaginal delivery. Birth trauma in infants can include injuries like bruises, fractures, and head trauma due to various factors during the delivery process. It is important to weigh the risks and benefits of delivery methods in consultation with healthcare providers to minimize the chances of birth trauma.