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A nurse is assessing a client who is in active labor. The client reports back labor pains.
Which of the following nonpharmacological interventions should the nurse provide to manage the client's pain?

A.

Teach the client patterned breathing techniques.

B.

Encourage the support person to perform effleurage.

C.

Encourage the support person to apply sacral counterpressure.

D.

Teach the client to use guided imagery.

E.

Teach the client to use guided imagery.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Patterned breathing techniques can help in managing pain by focusing on controlled breathing, reducing anxiety, and providing a distraction from the pain, but are not specifically targeting back labor pains.

 

Choice B rationale

Effleurage involves light circular strokes on the abdomen and can help in managing general labor pain, but may not be as effective specifically for back labor pains.

 

Choice C rationale

Sacral counterpressure involves applying steady pressure to the sacral area, which can help relieve pain caused by back labor by counteracting the discomfort experienced in this

area.

 

Choice D rationale

Guided imagery involves using mental visualization to distract from pain and promote relaxation, but may not be as effective in relieving the specific pain associated with back labor.


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Correct Answer is A

Explanation

Choice A rationale

Fetal heart rate (FHR) accelerations with fetal movement are a sign of a healthy and reactive nonstress test. This indicates that the fetus is well-oxygenated and there is no immediate distress.

Choice B rationale

Late decelerations of the FHR occur with contractions and are a concern for fetal hypoxia. This does not indicate a reactive nonstress test and instead suggests the need for further evaluation.

Choice C rationale

Variable decelerations are abrupt decreases in FHR and could indicate umbilical cord compression. This does not correlate with a reactive nonstress test.

Choice D rationale

FHR pattern with minimal variability can be a sign of fetal distress or compromised oxygenation. It is not indicative of a reactive nonstress test.

Correct Answer is B

Explanation

Choice A rationale

Holding the newborn during the initial visit may make the older sibling feel left out or jealous. Encouraging involvement with the new baby may be more beneficial.

Choice B rationale

Spending individual time with the older sibling helps them feel valued and ensures they do not feel neglected, facilitating better acceptance of the newborn.

Choice C rationale

Having the older sibling purchase a gift for the newborn can create a positive association, but it is less impactful than ensuring individual time and attention.

Choice D rationale

Postponing the introduction until discharge can increase feelings of jealousy or resentment, as the older sibling might feel excluded from the new family dynamic during a crucial time.

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