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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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

A positive pregnancy test is a probable sign of pregnancy as it indicates the presence of hCG, a hormone produced during pregnancy. However, it is not a presumptive sign, as other

conditions can also result in elevated hCG levels.

Choice B rationale

Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy. It is one of the earliest indications that a woman may be pregnant, though it can also be

caused by other factors such as stress or hormonal imbalances.

Choice C rationale

Fetal heart sounds detected by Doppler ultrasound are a positive sign of pregnancy, confirming the presence of a fetus. This is not a presumptive sign as it is direct evidence of

pregnancy.

Choice D rationale

Chadwick's sign, a bluish discoloration of the cervix, vagina, and labia due to increased blood flow, is considered a probable sign of pregnancy. It is not a presumptive sign but rather

a physical change that occurs during pregnancy. .

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

Hypertension is not a characteristic finding of hyperemesis gravidarum, which primarily affects fluid balance and nutritional status.

Choice B rationale

Dry mucous membranes are a sign of dehydration, commonly associated with hyperemesis gravidarum due to excessive vomiting.

Choice C rationale

Tachycardia can result from dehydration and electrolyte imbalances seen in hyperemesis gravidarum.

Choice D rationale

Poor skin turgor indicates dehydration, a common symptom of hyperemesis gravidarum.

Choice E rationale

Polyuria is not typical in hyperemesis gravidarum; the condition usually leads to dehydration, reducing urine output.

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