Chapter 14: PAIN MGMT

A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: 1 counterpressure against the sacrum. 2 pant-blow (breaths and puffs) breathing techniques. 3 effleurage. 4 biofeedback

1 Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's most appropriate analgesic for pain control is: 1 fentanyl (Sublimaze). 2 promethazine (Phenergan). 3 butorphanol tartrate (Stadol). 4 nalbuphine (Nubain)

1 Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use.

What kind of anesthesia does the nurse expect the primary health care provider to prescribe to a patient who is to have an emergency cesarean birth due to fetal distress? 1 General anesthesia 2 Pudendal nerve block 3 Nitrous oxide with oxygen 4 Local infiltration anesthesia

1 General anesthesia may be necessary if indications necessitate rapid birth (vaginal or emergent cesarean), when there is a pressing need for time and/or primary health care providers to perform a block. Pudendal nerve block is administered late in the second stage of labor. It may be required if an episiotomy is to be performed or if forceps or a vacuum extractor is to be used to facilitate birth. Nitrous oxide mixed with oxygen can be inhaled in 50% or less concentration to provide analgesia during the first and second stages of labor. Local infiltration anesthesia may be used when an episiotomy is to be performed or when lacerations must be sutured after birth in a woman who does not have regional anesthesia. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.

The nurse is caring for a patient who is administered local perineal infiltration anesthesia. In what situation does the nurse expect the use of local perineal infiltration anesthesia? When a(n): 1 Episiotomy is required. 2 Forceps birth is expected. 3 Cesarean birth is expected. 4 Vacuum extractor is to be used.

1 Local perineal infiltration anesthesia may be used when an episiotomy is to be performed. It may also be used when lacerations must be sutured after birth in a patient who does not have regional anesthesia. Pudendal nerve block is administered late in the second stage of labor if an episiotomy is to be performed or if forceps or a vacuum extractor is to be used to facilitate birth. Low spinal anesthesia (block) may be used for cesarean birth.

A patient who is pregnant for the first time is anxious about the pain related to labor. Which physiologic factor does the nurse relate that may increase the intensity of pain during childbirth? 1 History of dysmenorrhea 2 Low level of prostaglandin 3 Cramps during menstruation 4 High level of β-endorphin

1 Patients with a history of dysmenorrhea may experience increased pain during childbirth. These patients are known to have high levels of prostaglandin. Low levels of prostaglandin do not increase the intensity of pain during labor. The level of beta (β) endorphins increases during pregnancy and birth. β endorphins are endogenous opioids that reduce pain. Back pain associated with menstruation also increases the likelihood of contraction-related low back pain.

Nurses should be aware of the difference experience can make in labor pain, such as: 1 sensory pain for nulliparous women often is greater than for multiparous women during early labor. 2 affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. 3 women with a history of substance abuse experience more pain during labor. 4 multiparous women have more fatigue from labor and therefore experience more pain.

1 Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue. Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.

The nurse is teaching a class on childbirth. What does the nurse teach about signs of local anesthetic toxicity? Select all that apply. 1 Tinnitus 2 Metallic taste 3 Slurred speech 4 Long stage II labor 5 Increased use of oxytocin

1, 2, 3 The central nervous system can be affected if a local anesthetic agent is injected accidentally into a blood vessel leading to local anesthetic toxicity . Signs include metallic taste, tinnitus, and slurred speech. Longer stage II labor and increased use of oxytocin are side effects of epidural and spinal anesthesia.

The nurse is teaching pain relief techniques to a group of expectant patients. What does the nurse teach the patients about the gate-control theory of pain? 1 Distractions block the nerve pathways. 2 Neuromuscular activity can increase pain. 3 All sensations travel together to the brain. 4 Motor activity during labor intensifies pain

1 The gate-control theory of pain explains the way pain relief techniques work to relieve the pain of labor. Distractions close down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. According to this theory only a limited number of sensations can travel through the sensory nerve pathways to the brain at one time. When the laboring patient engages in motor activity and neuromuscular activity, activity within the spinal cord itself further modifies the transmission of pain. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

What interventions does the nurse perform for a laboring patient with hypotension and fetal bradycardia? Select all that apply. 1 Notify the primary health care provider or anesthesiologist. 2 Monitor the fetal heart rate (FHR) every 5 minutes. 3 Monitor maternal blood pressure every 10 minutes. 4 Administer oxygen using a non rebreather facemask. 5 Position the patient in Sims' or modified Sims' position.

1, 2, 4 The nurse must immediately notify the primary health care provider, anesthesiologist, or nurse anesthetist. The nurse must administer oxygen by nonrebreather facemask at 10 to 12 L/min or as per health care facility's protocol. The FHR must be monitored every 5 minutes. The patient must be turned to lateral position or a pillow or wedge must be placed under a hip to displace the uterus. Sims' or modified Sims' position may be used when spinal anesthesia is administered. Maternal blood pressure must be monitored every 5 minutes.

The nurse teaches the patient nonpharmacologic pain management methods during a prenatal class. Which methods require practice for best results? Select all that apply. 1 Biofeedback 2 Massage and touch 3 Patterned breathing 4 Controlled relaxation 5 Slow-paced breathing

1, 3, 4 Patterned breathing, controlled relaxation, and biofeedback techniques must be practiced to obtain best results. Patterned breathing and controlled relaxations help to manage pain during labor. Biofeedback is effective when the patient is able to focus and control body responses during labor. The nurse assisting the laboring patient can use methods such as massage and touch and slow-paced breathing successfully without the patient having any prior knowledge about it.

A patient inquires about the use of hypnosis for pain management during a prenatal assessment. What does the nurse teach the patient about this modality? Select all that apply. 1 It gives a better sense of control. 2 It must be performed by a support person. 3 It is a form of deep relaxation or meditation. 4 It is more effective than the use of a placebo. 5 It can cause dizziness, nausea, and headache

1, 3, 5 Hypnosis is a form of deep relaxation, similar to daydreaming or meditation. It enhances relaxation and diminishes fear, anxiety, and perception of pain. It allows the patient to have a greater sense of control over painful contractions. Failure to dehypnotize properly may result in mild dizziness, nausea, and headache. Self-hypnosis must be learnt during childbirth preparation classes. It is not performed by a support person. Although hypnosis is beneficial, studies have not found it to be more effective than the use of a placebo or other interventions for pain management during labor.

What interventions does the nurse perform to provide emotional support to a patient in labor? Select all that apply. 1 Compliment patient efforts during labor. 2 Avoid offering food during labor. 3 Use a calm, confident approach. 4 Discourage activities that distract. 5 Involve the patient in care decisions.

1, 3, 5 The nurse must offer emotional support by complimenting the patient and offering positive reinforcement for efforts during labor. The patient must be involved in decision making regarding own care. The nurse must use a calm and confident approach when assisting the patient during labor. The nurse may offer food and nourishment, if allowed by the primary health care provider. The nurse must encourage participation in distracting activities and nonpharmacologic measures for comfort.

The nurse is teaching a couple about the use of imagery and visualization in managing pain during labor. What is the patient expected to do during this technique? Select all that apply. 1 Imagine breathing in light and energy. 2 Maintain clenched fists to drive out pain. 3 Engage in dance or rhythmic movements. 4 Imagine walking through a restful garden. 5 Envisage breathing out worries and tension.

1, 4, 5 Imagery and visualization are useful techniques in preparation for birth and are often used in combination with relaxation. Imagery involves techniques, such as breathing in light and energy, imagining a walk through a restful garden, or envisaging breathing out worries and tension. Relaxation or reduction of body tension is a technique that involves rhythmic motion that stimulates the mechanoreceptors of the brain. The nurse must recognize the signs of tension, such as clenching of fists when in pain by the laboring patient.

The nurse teaches acupressure methods for pain relief during labor to a couple in the prenatal clinic. What does the nurse teach about acupressure? Select all that apply. 1 Blood circulation is enhanced. 2 Flow of qi (energy) is restored. 3 Lubricants are used over the area. 4 Pressure is applied with the fingers. 5 Pressure is applied with contractions.

1, 4, 5 Pressure is usually applied with the heel of the hand, fist, or pads of the thumbs and fingers. Pressure is applied with contractions initially and then continuously as labor progresses to the transition phase at the end of the first stage of labor. Acupressure is said to promote the circulation of the blood, the harmony of yin and yang, and the secretion of neurotransmitters. Thus acupressure maintains normal body functions and enhances well-being. Acupressure is applied over the skin without using lubricants. In acupuncture, the flow of qi (energy) is restored.

The nurse acts as an advocate for the patient during an informed consent. What care must the nurse take while obtaining an informed consent? Select all that apply. 1 Check for the patient's signature. 2 Ensure that the consent is in English. 3 Obtain a family member's signature. 4 Check for the date on the consent form. 5 Check the anesthetic care provider's signature.

1, 4, 5 The nurse must ensure that the consent form has the correct date. The nurse must ensure that the patient has not been compelled to consent for the procedure. The form must carry the signature of the anesthetic care provider, certifying that the patient has received and expresses understanding of the explanation. The consent form must be written or explained in the patient's primary language. The nurse need not obtain a family member's signature on the document. The patient's signature is important.

What care must the nurse take when implementing aromatherapy for a patient in labor? 1 Apply oil to the skin and massage. 2 Ask the patient to choose the scents. 3 Apply a few drops of oil to the hair. 4 Allow inhalation of warm oil vapors

2 Certain scents can evoke pleasant memories and feelings of love and security. So, it is helpful if the patient is allowed to choose the scents. The oils must never be applied in full strength directly on to the skin. Most oils should be diluted in a vegetable oil base before use. Inhaling vapors from the oil can lead to unpleasant side effects like nausea or headache. Drops of essential oils can be put on a pillow or on a woman's brow or palms or used as an ingredient in creating massage oil. It is not applied to the hair. STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.

The nurse is assisting a patient in labor. What breathing pattern must the nurse remind the patient to use when the contractions increase in frequency and intensity in the first phase of labor? 1 Slow-paced breathing 2 Modified-paced breathing 3 3:1 pattern-paced breathing 4 4:1 pattern-paced breathing

2 During the first phase of labor, as contractions increase in frequency and intensity, the patient must change breathing patterns to a modified-paced breathing technique. This breathing pattern is shallower and faster than the patient's normal rate of breathing, but should not exceed twice the resting respiratory rate. Slow-paced breathing is performed at approximately half the normal breathing rate and is initiated when the patient can no longer walk or talk through contractions. Patterned-paced breathing is suggested in the second phase of labor. It consists of panting breaths combined with soft blowing breaths at regular intervals. The patterns may vary, the 3:1 pattern is pant, pant, pant, blow and the 4:1 pattern is pant, pant, pant, pant, and blow.

What does the nurse teach the patient about the benefits of breathing techniques in the second stage of labor? 1 Does not interfere with fetal descent 2 Causes increase in abdominal pressure 3 Reduces discomfort during contractions 4 Increases the size of the abdominal cavity

2 In the second stage of labor breathing technique is used to increase abdominal pressure and expel the fetus. In the first stage of labor, breathing helps to promote the relaxation of the abdominal muscles, thereby increasing the size of the abdominal cavity. This lessens the discomfort during contraction caused by the friction between the abdominal wall and the uterus. It also relaxes the muscles of the genital area and does not interfere with fetal descent. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question.

The nurse is assisting a patient who is prepared to use the paced breathing method. What does the nurse remind the patient to do at the beginning of the breathing pattern? 1 Exhale a deep breath. 2 Take a deep relaxing breath. 3 Take 32 breaths per minute. 4 Take three breaths per minute.

2 The patient must remember that all breathing patterns begin with a deep, relaxing "cleansing breath" to "greet the contraction." The patient must then exhale a deep breath to "blow the contraction away." These deep breaths ensure adequate oxygen for the mother and the baby and signal that a contraction is beginning or has ended. The patient must take three to four breaths per minute when performing slow-paced breathing. As contractions increase in frequency and intensity, the patient takes shallow, fast breaths, about 32 to 40 per minute.

During a prenatal assessment a patient asks the nurse about the disadvantages of spinal anesthesia. What does the nurse teach the patient about the potential effect of spinal anesthesia? 1 It reduces maternal consciousness. 2 It increases maternal muscular tension. 3 It increases probability of operative birth. 4 It increases the possibility of fetal hypoxia.

3 When a spinal anesthetic is given, the need for episiotomy, forceps-assisted birth, or vacuum-assisted birth tends to increase because voluntary expulsive efforts are reduced or eliminated. Maternal consciousness is maintained. Fetal hypoxia is absent as maternal blood pressure is maintained within a normal range. There is no muscular tension; excellent muscular relaxation is achieved.

What major side effect does the nurse expect if a patient in labor is administered diazepam (Valium)? 1 Severe nausea and vomiting in the mother 2 Neonatal central nervous system depression 3 Disrupted temperature control in the newborn 4 Magnified pain if administered without analgesic

3 Diazepam (Valium) disrupts thermoregulation in the newborn. Thus the newborn is less able to maintain body temperature. Benzodiazepines, when given with an opioid analgesic, seem to enhance pain relief and reduce nausea and vomiting. Pain is magnified if a barbiturate is given without an analgesic to a patient who is experiencing pain. This is because the normal coping mechanism in the patient may be blunted. Barbiturates should be avoided if birth is anticipated within 12 to 24 hours because it has the potential to cause neonatal central nervous system depression.

The nurse is caring for a patient who is using fentanyl citrate (Sublimaze) through patient-controlled analgesia (PCA) while in labor. What effects of fentanyl citrate does the nurse expect? 1 Provides long duration of action 2 Requires only a single dose 3 Provides quick relief to pain 4 Causes sedation and nausea

3 Fentanyl citrate (Sublimaze) is a potent short-acting opioid agonist analgesic. Therefore it provides quick pain relief. It rapidly crosses the placenta, so it is present in the fetal blood within 1 minute after intravenous maternal administration. It is a short-acting drug, so the patient will require more frequent dosing. It is often administered as a patient controlled analgesic. It has fewer neonatal effects as compared to meperidine, and causes less maternal sedation and nausea.

The nurse is caring for a nulliparous patient in labor. How is the experience for a nulliparous patient different from that of a multiparous patient? The patient experiences: 1 Less sensory pain during early labor. 2 Greater sensory pain in the second stage of labor. 3 Greater fatigue due to longer duration of labor. 4 Greater affective pain in the second stage of labor.

3 Parity influences the perception of labor pain. The nulliparous patient often has longer labor and therefore, greater fatigue. Sensory pain for nulliparous women is often greater than that for multiparous women during early labor, because their reproductive tract structures are less supple. Affective pain in the nulliparous patient is greater in the first stage as compared to a multiparous patient. It decreases for both patients during the second stage of labor. During the second stage of labor, the multiparous patient may experience greater sensory pain than the nulliparous patient. This is because tissues of the multiparous patient are more supple and increase the speed of fetal descent, thereby intensifying the pain. Test-Taking Tip: Answer every question because, on the NCLEX exam, you must answer a question before you can move on to the next question.

What intervention does the nurse perform to provide a relaxed environment for labor? 1 Stand at the bedside. 2 Encourage rapid birth. 3 Control sensory stimuli. 4 Demonstrate excitement

3 The nurse must assist the patient by providing a quiet and relaxed environment. A relaxed environment for labor is created by controlling sensory stimuli, such as light, noise, and temperature, as per the patient's preferences. The nurse must provide reassurance and comfort by sitting rather than standing at the bedside whenever possible. The nurse must not encourage or hurry the patient for rapid birth. The nurse must maintain a calm and unhurried attitude when caring for the patient. Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.

During the second phase of labor the patient initiates pattern-paced breathing. What adverse symptoms must the nurse watch for when the patient initiates this method? 1 Pallor 2 Nausea 3 Dizziness 4 Diaphoresis

3 The nurse must watch for symptoms of hyperventilation and resulting respiratory alkalosis. Symptoms of respiratory alkalosis during pattern-paced breathing include dizziness, light-headedness, tingling of fingers, or circumoral numbness. Pallor, nausea, and diaphoresis are generally observed in the active and transition phases of the first stage of labor. They are physiologic effects of pain.

During the prenatal assessment of a patient, the nurse teaches the patient about nonpharmacologic pain management. What does the nurse tell the patient about this method? 1 It is technical and expensive. 2 It requires intensive training. 3 It provides the patient with a sense of control. 4 It is used only in stage I of labor.

3 The patient makes choices about the nonpharmacologic pain management methods that are best suited. This provides the patient with a sense of control over childbirth. These measures are relatively simple and inexpensive. They do not require intensive training. However, the patient may obtain best results from the practice. It can be used throughout labor.

A patient asks the nurse about the use of transcutaneous electrical nerve stimulation (TENS). What does the nurse teach about TENS? 1 It involves the use of one pair of electrodes. 2 It is kept at low intensity during contractions. 3 It releases continuous low-intensity impulses. 4 It is useful for pain in the second stage of labor.

3 When TENS is applied for pain relief, the electrodes provide continuous low-intensity electrical impulses or stimuli from a battery-operated device. TENS is most useful for lower back pain during the early first stage of labor. TENS involves the placing of two pairs of flat electrodes on either side of the woman's thoracic and sacral spine. During a contraction, the patient increases the stimulation from low to high intensity by turning the control knobs on the device.

What care must the nurse take when assisting a laboring patient with hydrotherapy? 1 Initiate hydrotherapy in the first stage of labor at 3 cm. 2 Ensure water is warm at 32.5° to 34° C (90.5° to 93.2°F). 3 Check the fetal heart rate (FHR) with internal electrodes. 4 Obtain the approval of the primary health care provider.

4 Agency policy must be consulted to determine if the approval of the laboring woman's primary health care provider is required. The nurse must ensure that all criteria are met in terms of the status of the maternal and fetal unit. Hydrotherapy is usually initiated when the patient is in active labor, at approximately 5 cm. This reduces the risk of a prolonged labor. FHR monitoring is done by Doppler, fetoscope, or wireless external monitor when hydrotherapy is in use. Use of internal electrodes for monitoring FHR is contraindicated in jet hydrotherapy. The temperature of the water should be maintained at 36° to 37° C (96.8° to 98.6° F). Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

The nurse is caring for a patient in the last trimester of pregnancy. What assessments will the patient display related to the effects of fear and anxiety during labor? An increase in: 1 Blood flow. 2 The progression of labor. 3 Contractions. 4 Muscle tension

4 Fear and excessive anxiety leads to increased muscle tension. It causes more catecholamine secretion. This increases the stimuli to the brain from the pelvis due to increased muscle tension and decreased blood flow. Thus fear and anxiety magnifies the perception of pain. Anxiety does not increase uterine contractions, but reduces the effectiveness of the contractions leading to increased discomfort. This slows the progress of labor. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.

When caring for a patient in the first phase of labor, the nurse observes that the patient is experiencing visceral pain. In which area does visceral pain occur? 1 Abdominal wall and thighs 2 Gluteal area and iliac crests 3 Lumbosacral area of the back 4 Lower portion of the abdomen

4 Visceral pain in the first stage of labor occurs in the lower portion of the abdomen. Visceral pain is a result of distention of the lower uterine segment and stretching of cervical tissue as it effaces and dilates. Pressure and traction on uterine tubes, ovaries, ligaments, nerves, and uterine ischemia also cause visceral pain. Pain that originates in the uterus radiates to the gluteal area, iliac crests, abdominal wall, thighs, lumbosacral area of the back, and lower back. This pain is called referred pain.