Nursing Management of Pain During Labor and Birth

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use: a. Counterpressure against the sacrum. b. Pant-blow (breaths and puffs) breathing techniques. c. Effleurage. d. Conscious relaxation or guided imagery.

ANS: A 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. The pain management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory.

A woman is 1 hour postpartum with an epidural block and wishes to get up to go to the bathroom. What action by the nurse is most appropriate? A. Assess sensation in the lower extremities. B. Check the maternal vital signs. C. Confer with the health-care provider. D. Offer the woman the bedpan first.

ANS: A After an epidural block, the nurse must assess for intact sensation in the woman's lower extremities prior to allowing ambulation. This action ensures patient safety. The other options are not related to ambulating after an epidural block.

What chemical substance(s) produced in the body acts as a natural pain reliever? a. Endorphins b. Morphine c. Codeine d. Atropine

ANS: A Endorphins are natural body substances that are similar to morphine and may explain why laboring women need smaller doses of analgesia

An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, "Please give me something for the pain. I can't take the pain!" What is the priority nursing diagnosis? a. Pain related to uterine contractions b. Knowledge deficit related to the birth experience c. Ineffective coping related to inadequate preparation for labor d. Risk for injury related to lack of prenatal care

ANS: A The most important issue for this woman, at this time, is effective pain management.

A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction? a. Use slow-paced breathing. b. Hold her breath and push. c. Blow in short breaths. d. Use rapid-paced breathing.

ANS: C If a laboring woman feels the urge to push before the cervix is fully dilated, then she is taught to blow in short breaths to avoid bearing down.

The woman in labor is complaining of severe back pain. What action should the nurse suggest to the birth partner? A. Apply counterpressure B. Give a hand massage C. Perform effleurage D. Provide therapeutic touch

ANS: A Counterpressure is performed when the support person uses the fist or heel of the hand to apply steady pressure to the sacral area. This can be especially helpful when the woman is having back pain due to the pressure of the occiput against spinal nerves while the fetus is in a posterior position. Massage has demonstrated some usefulness, but more studies are needed. Effleurage is a gentle stroking technique performed in rhythm with contractions. Therapeutic touch is provided by trained personnel.

A nurse instructs a woman's labor coach to comfort her by firmly pressing on her lower back. What is this technique? a. Sacral pressure b. Distraction c. Effleurage d. Conscious relaxation

ANS: A Sacral pressure refers to firm pressure against the lower back to relieve some of the pain of back labor.

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is called: a. An epidural. b. A pudendal. c. A local. d. A spinal block.

ANS: B A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

With regard to a pregnant woman's anxiety and pain experience, nurses should be aware that: a. Even mild anxiety must be treated. b. Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on. c. Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

ANS: B Anxiety and pain reinforce each other in a negative cycle. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can build sufficiently to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.

With regard to systemic analgesics administered during labor, nurses should be aware that: a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b. Effects on the fetus and newborn can include decreased alertness and delayed sucking. c. Intramuscular administration (IM) is preferred over intravenous (IV) administration. d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

ANS: B Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic.

A labor and delivery nurse explains to the student that the most common complication following a spinal anesthesia block is which of the following? A. Fetal depression B. Hematoma C. Maternal hypotension D. Severe pruritus

ANS: C The most common complication seen with the use of spinal anesthesia blocks is maternal hypotension. The other options are less common complication

A woman in labor has just received an epidural block. The most important nursing intervention is to: a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

ANS: C The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural, to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension.

Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth. What does the nurse recognize these symptoms signify? a. Hypertension b. Anxiety c. Anoxia d. Hyperventilation

ANS: D Hyperventilation is sometimes a problem if a woman is breathing rapidly.

The physician has ordered Fentanyl (Sublimaze) for a woman in labor and has asked the nurse to provide patient education. What will the nurse include in the educational plan? (Select all that apply.) a. Onset is slow. b. Duration is short. c. Administration is by mouth. d. No known side effects. e. It is not the same drug as sufentanil.

ANS: B, E Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are not the same drugs. Fentanyl can cause respiratory depression but less than meperidine. It is not administered by mouth.

What is the Dick-Read method of childbirth preparation based on? a. Mild sedation throughout labor b. Relaxation techniques c. Skin stimulation d. Deep massage

ANS: B The Dick-Read method depends on the use of relaxation techniques to reduce the discomforts of labor.

With regard to nerve block analgesia and anesthesia, nurses should be aware that: a. Most local agents are related chemically to cocaine and end in the suffix -caine. b. Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. A pudendal nerve block is designed to relieve the pain from uterine contractions. d. A pudendal nerve block, if done correctly, does not significantly lessen the bearing-down reflex.

ANS: A Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions, and it lessens or shuts down the bearing-down reflex.

To help clients manage discomfort and pain during labor, nurses should be aware that: a. The predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen. b. Referred pain is the extreme discomfort between contractions. c. The somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the second stage.

ANS: A This pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage.

When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block? a. Abnormal clotting b. Previous cesarean delivery c. History of migraine headaches d. History of diabetes mellitus

ANS: A An epidural block is not used if a woman has abnormal blood clotting.

What breathing techniques would the nurse teach the prenatal patient to help her focus during labor in order to reduce pain? (Select all that apply.) a. First stage breathing b. Abdominal breathing c. Fourth stage breathing d. Modified pace breathing e. Patterned paced breathing

ANS: A, B, D, E First stage breathing includes the techniques of modified pace breathing and patterned paced breathing, which are types of abdominal breathing techniques. These patterns of breathing will help a woman in labor to focus and reduce pain perception. The fourth stage of labor is the woman's recovery stage and does not require a breathing technique.

How does the pain of childbirth differ from other types of pain? (Select all that apply.) a. Childbirth pain is part of a normal process. b. Childbirth pain seldom needs narcotic relief. c. Position changes relieve pain and facilitate delivery. d. Childbirth pain declines following birth. e. Childbirth pain is self-limited.

ANS: A, C, D, E Childbirth pain differs from other types of pain because it is part of a normal, natural, and expected process, can be relieved by change of position, declines immediately following birth, and is self-limiting. Childbirth pain requires pharmacological management with narcotics in many cases.

The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Signs of opioid/narcotic withdrawal in the mother would include (Select all that apply): a. Yawning, runny nose. b. Increase in appetite. c. Chills and hot flashes. d. Constipation. e. Irritability, restlessness.

ANS: A, C, E The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. It is important for the nurse to assess both mother and baby and to plan care accordingly.

It is important for the nurse to develop a realistic birth plan with the pregnant woman in her care. The nurse can explain that a major advantage of nonpharmacologic pain management is: a. Greater and more complete pain relief is possible. b. No side effects or risks to the fetus are involved. c. The woman remains fully alert at all times. d. A more rapid labor is likely.

ANS: B Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. The woman's alertness is not altered by medication; however, the increase in pain will decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace.

With regard to spinal and epidural (block) anesthesia, nurses should know that: a. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. b. A high incidence of after-birth headache is seen with spinal blocks. c. Epidural blocks allow the woman to move freely. d. Spinal and epidural blocks are never used together.

ANS: B Headaches may be prevented or mitigated to some degree by a number of methods. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

The anesthesia provider has just administered an epidural anesthetic in a laboring patient and local anesthesia is continuously infusing via the epidural catheter. Suddenly, the patient asks, "Why are my ears ringing?" What is the most likely cause of the patient's complaint? A. Hypotension B. Allergic reaction C. Dehydration D. Local anesthetic toxicity

ANS: D Although maternal hypotension is associated with epidural anesthesia, a sensation of ringing in the ears is associated with local anesthetic toxicity.

The perinatal nurse understands that the purpose of combining an opioid with a local anesthetic agent in an epidural is primarily for which of the following? A. Decrease the number of side effects B. Increase the intensity of the block C. Increase the total anesthetic volume D. Preserve more maternal motor function

ANS: D Combining an opioid with a local anesthetic agent reduces the total amount of anesthetic required and helps to preserve a greater amount of maternal motor function

What would the nurse guide a labor coach to do to comfort a woman tensing her muscles with contractions? a. Offer warm liquids to the patient. b. Encourage the patient to pant. c. Engage the patient in conversation. d. Assist the patient to the knee-chest position.

ANS: B Panting relaxes the abdominal wall and distracts the patient. It would not be helpful to offer fluids or to attempt conversation during contractions. Walking intensifies contractions.

Following spinal anesthesia for delivery of her baby, a woman reports an inability to void urine. As the nurse palpates the woman's bladder the woman says, "It's been five hours since I had my spinal and I still can't empty my bladder. Do I have nerve damage?" How should the nurse respond? A. "Spinal anesthesia can sometimes cause nerve damage." B. "It may be several hours before you're able to control your urination." C. "You should be able to control your bladder by now. I'll ask the anesthesia provider to visit with you." D. "You are probably dehydrated. Please increase your water intake."

ANS: B Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. Although nerve damage is a rare occurrence in relation to spinal anesthesia, there is no objective data to suggest that this woman has experienced nerve damage. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. There is no data to suggest the woman is dehydrated. Rather, she is likely demonstrating a common side effect of spinal anesthesia. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

A nurse is caring for a woman who is going to have an epidural block. The physician orders that an IV be started. Which of the following solutions would be appropriate for the nurse to choose? (Select all that apply.) A. D5 (5% dextrose) with 0.45 normal saline (NS) B. D5 and water (D5W) C. Lactated Ringer's (LR) solution D. Normal saline (NS) E. Normal saline (NS) with 10% dextrose

ANS: C, D Most institutions use dextrose-free IV solutions for women in labor because dextrose can cause fetal hyperglycemia with rebound hypoglycemia in the few hours after birth. The other three options all contain dextrose.

What is the least amount of sensation that one perceives as pain? a. Tolerance b. Threshold c. Level d. Abatement

ANS: B Pain threshold is the least amount of sensation that one perceives as pain. Thresholds are different for each individual.

The perinatal nurse is caring for a woman in early labor with a fetus in the occiput posterior position. What action should the nurse perform to increase the woman's comfort? A. Assist the woman into a hands-and-knees position. B. Encourage the woman to assume a sitting position. C. Have the woman walk to the bathroom and void. D. Provide soothing music as a distraction technique

ANS: A Assuming a hands-and-knees position will help relieve the pressure on the woman's back when the fetus is in a posterior position. This also helps the fetus rotate to a more favorable position. The other interventions will not be as helpful.

With regard to breathing techniques during labor, maternity nurses should understand that: a. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. b. By the time labor has begun, it is too late for instruction in breathing and relaxation. c. Controlled breathing techniques are most difficult near the end of the second stage of labor. d. The patterned-paced breathing technique can help prevent hyperventilation.

ANS: A First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.

A woman in active labor receives an analgesic opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease? a. Meperidine (Demerol) b. Promethazine (Phenergan) c. Butorphanol tartrate (Stadol) d. Nalbuphine (Nubain)

ANS: A Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Stadol and Nubain are opioid agonist-antagonist analgesics.

Nurses should be aware of the differences experience can make in labor pain such as: a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor. b. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

ANS: A 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.

A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics often are used with sedatives because: a. "The two together work the best for you and your baby." b. "Sedatives help the opioid work better, and they also will assist you to relax and relieve your nausea." c. "They work better together so you can sleep until you have the baby." d. "This is what the doctor has ordered for you."

ANS: B Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two drugs to work together more effectively, but it does not ensure maternal or fetal complications will not occur. Sedation may be a related effect of some ataractics, but it is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. "This is what the doctor has ordered for you" may be true, but it is not an acceptable comment for the nurse to make.

The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if: a. The mother gives birth without any analgesic or anesthetic. b. The mother and family's priorities and preferences are incorporated into the plan. c. The primary health care provider decides the best pain relief for the mother and family. d. The nurse informs the family of all alternative methods of pain relief available in the hospital setting.

ANS: B The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers, who consult with the woman about their findings and recommendations. The needs of each woman are different, and many factors must be considered before a decision is made whether pharmacologic methods, nonpharmacologic methods, or a combination of the two will be used to manage labor pain.

The nurse coaches the primigravida not to bear down until the cervix is completely dilated. What may premature bearing down cause? a. Increased use of oxygen b. Cervical laceration c. Uterine rupture d. Compression of the cord

ANS: B Bearing down against a cervix that is not dilated can cause edema and laceration to the cervix.

If an opioid antagonist is administered to a laboring woman, she should be told that: a. Her pain will decrease. b. Her pain will return. c. She will feel less anxious. d. She will no longer feel the urge to push.

ANS: B The woman should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist. Opioid antagonists, such as Narcan, promptly reverse the central nervous system (CNS) depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when the opioid is at its peak effect.

A laboring patient has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, the nurse would expect to do which of the following? A. Observe fetal heart rate variability B. Rapidly infuse 500-1,000 ml of intravenous fluids. C. Place the patient in the semi-Fowler's position D. Teach the patient appropriate breathing techniques

ANS: B Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage to the procedure.

A nurse is teaching a woman about pain management strategies during labor. The woman expresses great fear about the experience. Which of the following statements by the nurse would help to ease the woman's fears? (Select all that apply.) A. "Don't worry about the pain; at least it's not from illness." B. "Keep in mind there is an end to the pain with the birth." C. "Pain during labor is normal and expected, and helps you to give birth." D. "We can anticipate your labor pain and plan for it." E. "You have to expect some amount of pain during labor."

ANS: B, C, D Labor pain has some unique characteristics, including: (1) being part of a normal process, as opposed to being caused by illness or injury; (2) being anticipated, which allows for planning and preparation; and (3) having an end point with the birth of the baby. The nurse should inform the pregnant woman about these facts in a supportive, encouraging way. Stating "at least it's not from illness" is factual but dismissive of her fears. Stating that she has to expect some pain is also dismissive and gives the impression that wanting pain control is unreasonable.

The nurse is providing a conference on nonpharmacological pain control methods. What major advantages of nonpharmacological pain control methods will the nurse include in the presentation? (Select all that apply.) a. They sedate the mother. b. They do not slow labor. c. They do not dull the excitement of the birth experience. d. They do not have the potential to cause allergic reactions. e. They do not have to be delayed until labor is well established

ANS: B, C, D, E All the options mentioned are benefits of nonpharmacological pain control methods with the exception of sedating the mother.

Which position(s) and exercise(s) will the nurse teach as beneficial in combating discomfort in the later stages of pregnancy? (Select all that apply.) a. Leg lifts b. Pelvic rock c. Tailor sitting d. Sit-ups e. Shoulder curling

ANS: B, C, E Pelvic rock, tailor sitting, and shoulder curling are beneficial to the muscles that will have to adapt to the extra weight and changed posture of later pregnancy. Leg lifts and sit-ups are not beneficial because they both increase intraabdominal pressure.

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dL, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman? a. She is too far dilated. b. She is anemic. c. She has thrombocytopenia. d. She is septic.

ANS: C The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to epidural analgesia/anesthesia. Typically epidural analgesia/anesthesia is used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the woman's hemoglobin and hematocrit are in the normal range and show a slight increase in the WBC count that is not uncommon in laboring women.

The perinatal nurse suggests that a laboring woman may wish to use the birth ball. The patient questions the rationale for this suggestion. The best answer by the nurse is that use of the birth ball will facilitate what action? A. Decreased maternal anxiety B. Decreased transmission of pain C. Fetal descent D. Increased number of opioid receptors

ANS: C Assuming a sitting position on the birth ball facilitates a supported squatting position that opens the pelvis to allow fetal descent in preparation for birth.

What nursing intervention would be most important for a postpartum woman who received spinal anesthesia? A. Assess vital signs. B. Facilitate bonding. C. Monitor urine output. D. Promote breastfeeding.

ANS: C Because spinal anesthesia can cause bladder atony, it is important for the nurse to monitor the postpartum woman's urine output. Assessing vital signs and promoting bonding are important for all new mothers. Nurses should promote breastfeeding if this is the woman's preference.

The perinatal nurse is assessing a 36-year-old woman at term who is in early labor. The nurse assesses for findings that indicate pain, including which of the following? (Select all that apply.) A. Blood pressure: 100/64 mm Hg B. Frequent voiding in small amounts C. Increased irritability related to repeated questions D. Pulse rate of 106 beats per minute E. Verbalizing concern with coping ability

ANS: C, D, E During the assessment, the nurse may identify physiological and psychological changes that are indicative of maternal pain. These include an increased pulse rate and blood pressure, changes in mood, increased anxiety and stress, marked agitation, confusion, decreased urine output, decreased intestinal motility, and guarding of the target area of discomfort. Frequent voiding in small amounts and a normal blood pressure are not findings consistent with labor pain.

In the current practice of childbirth preparation, emphasis is placed on: a. The Dick-Read (natural) childbirth method. b. The Lamaze (psychoprophylactic) method. c. The Bradley (husband-coached) method. d. Having expectant parents attend childbirth preparation in any or no specific method.

ANS: D Encouraging expectant parents to attend childbirth preparation class is most important because preparation increases a woman's confidence and thus her ability to cope with labor and birth. Although still popular, the "method" format of classes is being replaced with other offerings such as Hypnobirthing and Birthing from Within.

Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that: a. Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. b. Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. Effleurage is permissible, but counterpressure is almost always counterproductive. d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

ANS: D Transcutaneous electrical nerve stimulation does help. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks may be more effective than a long soak. Counterpressure can help the woman cope with lower back pain.

A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what associated side effect of this type of regional anesthesia? a. Reduced fetal heart rate b. Long, intense contractions c. Sudden leg cramps d. Bladder distention

ANS: D A side effect of an epidural block is urine retention because the anesthesia interferes with the woman's ability to have an urge to void. The patient may have to be catheterized.

The nurse who encourages the gate control theory of pain control would advise a woman in labor and her partner to use which nonpharmacological method of pain management? a. Slow abdominal breathing b. Guided relaxation c. Listening to music d. Massage

ANS: D According to the gate control theory, stimulating large-diameter nerve fibers temporarily interferes with conduction of impulses through small-diameter fibers. Massage is a technique that stimulates large-diameter fibers and "closes the gate.

A patient who received an epidural block asks why her blood pressure is taken so often. What is the nurse's best response to explain the frequent blood pressure assessments? a. They ensure that unsafe levels of hypertension do not occur. b. They help assess for the need for further pain relief. c. They monitor the progress of labor. d. They ensure adequate placental perfusion.

ANS: D The hypotension that accompanies an epidural block may cause inadequate perfusion of the placenta, leading to fetal hypoxia.

A pregnant woman is asking about a combined spinal-epidural analgesia for labor pain. What information about this method of analgesia should the nurse provide? A. Cannot be used if a cesarean birth is required B. Causes a total loss of muscle control C. Associated with a delayed onset of good pain control D. Associated with an increased risk of infection and headache

ANS: D This method requires puncture of the dura and placement of a catheter in the epidural space, so it is associated with a higher incidence of infection and postprocedure headache than other methods. The other options are not associated with the combined analgesia.

The perinatal nurse assesses a patient who is immersed in a water-filled tub during active labor. The assessments that indicate the hydrotherapy has been effective include which of the following? (Select all that apply.) A. Decreased fetal heart rate B. Increased maternal blood pressure C. Increased maternal temperature D. Increased uterine activity E. Patient's report of less pain

ANS: D, E Hydrotherapy is effective when it provides relief from labor discomfort and pain by decreasing maternal catecholamines, prompting an increase in the release of oxytocin (stimulates uterine contractions) and endorphins (reduce the perception of pain). With decreased catecholamine release, blood pressure should remain stable or decrease. Of course the patient's report of lessened pain is the most valuable assessment. During immersion, the maternal temperature and fetal heart rate should remain stable.

A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a need for further explanation about the pudendal block? a. "I'm having a contraction. Can I get the pudendal block now?" b. "I'll get the pudendal block right before I deliver." c. "The nurse midwife will insert the needles into my vagina." d. "It takes a few minutes after the medicine is administered to make me feel numb."

ANS: A The pudendal block does not block pain from contractions and is given just before birth.

A woman has just given birth to an infant weighing 9 lb, 15 oz (4,350 g) with the assistance of forceps and an episiotomy. The patient received a pudendal block 12 minutes before the birth. The perinatal nurse would expect which of the following responses to the block? A. Appropriate for adequate pain relief B. Too close to birth; causing fetal depression C. Too early and probably worn off D. Too late to provide anesthesia

ANS: A A pudendal nerve block provides pain relief in the lower vagina, vulva, and perineum. It should be administered 10 to 20 minutes before perineal anesthesia is needed and may be used late in the second stage of labor if an episiotomy is to be performed or if forceps or vacuum extraction will be used to facilitate birth.

The perinatal nurse prepares the laboring woman for an epidural anesthesia insertion. What action is best to help prevent maternal hypotension? A. Administer an intravenous infusion of 500 mL of normal saline. B. Assess vital signs every 5 minutes after the epidural insertion. C. Assist the woman to lie down in a supine position. D. Encourage frequent cleansing breaths during the procedure.

ANS: A Complications that may occur with spinal anesthesia block include maternal hypotension, decreased placental perfusion, and an ineffective breathing pattern. Prior to administration, the patient's fluid balance is assessed, and IV fluids are administered to reduce the potential for sympathetic blockade (decreased cardiac output that results from vasodilation with pooling of blood in the lower extremities). Following administration of the anesthetic, the patient's blood pressure, pulse and respirations, and fetal heart rate must be taken and documented every 5 to 10 minutes; however, assessing vital signs will not prevent hypotension from occurring. The woman is helped to a sitting position on the side of the bed. Deep cleansing breaths may be helpful for relaxation, but will not help prevent hypotension.

During her hospital admission, the laboring patient explicitly refused all pain medications and a labor epidural. Once dilated to 5 cm, the patient complains of intolerable discomfort and asks the nurse, "If I have an epidural, how will you make sure it doesn't hurt my baby?" The best response by the nurse is: A. "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural." B. "Epidural anesthesia is very safe and there are no potential side effects that can affect your baby." C. "We'll assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby D. Before your epidural is placed, we'll administer IV fluid to you in order to prevent the epidural from causing you problems."

ANS: A Continuous electronic fetal monitoring to assess fetal status is indicated in the care of pregnant women who receive epidural anesthesia and allows for a more direct assessment of fetal status than does frequent monitoring of maternal BP and pulse, which are also indicated in the care of this patient. While proficient administration and monitoring of epidural anesthesia allows for a high degree of safety with this technique, maternal hypotension associated with epidural anesthesia may produce harmful fetal effects. While frequent monitoring of maternal blood pressure and pulse are indicated in the care of a patient who receives a labor epidural, continuous electronic fetal monitoring is also indicated for assessment of fetal status and allows for a more direct fetal assessment. While administration of a bolus of IV fluid is indicated in preparation for epidural placement and reduces the risk for maternal hypotension, this intervention neither guarantees the prevention of related complications nor allows for assessment of fetal status.

The perinatal nurse is aware that a 25-year-old woman with gestational hypertension in labor would benefit most from which pharmacological pain relief medication? A. Epidural bupivacaine B. Fentanyl intravenously C. Morphine intrathecally D. Secobarbital sodium per mouth

ANS: A Epidural blocks are advantageous for patients with diabetes, heart disease, pulmonary disease, and, in some cases, gestational hypertension, because they essentially eliminate the pain associated with labor and thus reduce the maternal stress associated with labor discomfort.

The nurse is caring for a laboring patient who is receiving continuous epidural anesthesia via infusion. The maternal blood pressure decreases from 132/78 to 78/42. Which intervention should the nurse implement first? A. Increase the flow rate of infusion of intravenous crystalloid solution. B. Verify the patient is positioned to promote left uterine displacement C. Administer oxygen D. Administer ephedrine 5 to 10 mg intravenously.

ANS: A If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.

What is the most appropriate nursing action to take when a laboring woman hyperventilates? a. Help her breathe into her cupped hands. b. Place her flat on her back. c. Initiate oxygen at 2 liters via mask. d. Notify the doctor.

ANS: A Measures to combat hyperventilation include breathing into cupped hands or a paper bag or holding breath for a few seconds. All of these techniques decrease PCO2.

The laboring patient has rated her pain at 9 on a scale of 1-10, and she requests IV pain medication. She has refused epidural anesthesia, but her certified nurse-midwife (CNM) has ordered butorphanol tartrate (Stadol) for administration to the patient. Which action should the nurse complete next? A. Advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication. B. Offer the woman epidural anesthesia once more and describe the effectiveness of this method of labor pain control. C. Obtain maternal vital signs and assess the fetal heart rate (FHR). D. Administer oxygen via face mask at 6 to 10 liters per minute.

ANS: A Prior to administration of medication, the nurse must explain the pharmacologic effects of the medication and obtain consent for administration. The woman has refused epidural anesthesia but is authorized to receive butorphanol tartrate. The nurse's next step is to advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.Prior to obtaining maternal vital signs and assessing FHR, the nurse should advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication. Routine oxygen administration is not indicated for administration of butorphanol tartrate to an asymptomatic patient in labor. The nurse's next step is to advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.

A woman is using a birth ball to promote comfort and fetal descent. The nurse observes the woman rocking back and forth while sitting on the ball. What action by the nurse is most appropriate? A. Assess her response to the birth ball and document. B. Document that she is using the modality. C. Explain that she should move the ball in a circle. D. Instruct her to only use the birth ball for 10 minutes.

ANS: A The birth ball helps with comfort and fetal descent during labor. The patient is using it correctly; the two methods are moving it in a circle and rocking back and forth. The nurse should assess her response to this modality and document it. There is no time restriction on using a birth ball.

During admission, a laboring patient tells the nurse, "I'm so afraid I'll need a cesarean section. I don't want to be asleep for surgery when my baby is born!" Which of the following nursing responses is most appropriate? A. "If a cesarean section is needed, that doesn't necessarily mean you'll need to go to sleep for surgery B. "Your anesthesia provider will require that you go to sleep for surgery." C. "We'll do our best to make sure you deliver vaginally, so you don't need to have a cesarean section." D. "If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly."

ANS: A While general anesthesia may be needed for cesarean birth and for surgical intervention with some complications, in modern obstetrics, general anesthesia is used in less than 1% of all obstetric births.

A woman in labor receives a dose of hydromorphone hydrochloride (Dilaudid) at 11:30 a.m. She gives birth at 12:45 p.m. What action by the nurse takes priority? A. Assess the neonate frequently for respiratory depression. B. Encourage the woman to void every 2 hours postpartum. C. Perform a head-to-toe assessment on the neonate. D. Promote skin-to-skin contact and bonding as soon as possible.

ANS: A With Dilaudid, if birth occurs within 1 to 4 hours after administration, the nurse must assess the neonate frequently for respiratory depression. The other options are appropriate, but not the priority for this situation.

The perinatal nurse is caring for a woman with a postdural puncture headache. What interventions does the nurse include in this woman's care plan? (Select all that apply.) A. Bedrest B. Caffeine C. Decreased fluid intake D. Light therapy E. Position sitting upright

ANS: A, B Typically, the headache is intensified when the patient assumes an upright position and is relieved when she assumes a supine position. Interventions usually center on oral analgesics, bedrest in a darkened room, caffeine, and hydration. If these measures are not effective, an autologous epidural blood patch may be administered.

Which are nonpharmacological forms of pain relief? (Select all that apply.) a. Skin stimulation b. Diversion and distraction c. Breathing techniques d. Exercise e. Yoga

ANS: A, B, C Skin stimulation, diversion and distraction, and breathing techniques are the bases of nonpharmacological pain control. Although exercise and practices such as yoga and Pilates are beneficial, they are not means of pain control.

A nursing faculty member is explaining potential complications from epidural anesthesia to a class of nursing students. Which information does the nurse include? (Select all that apply.) A. Bizarre behavior B. Increased need for oxytocin (Pitocin) C. Lengthened duration of labor D. Shiver response E. Urinary incontinence

ANS: A, B, C, D Potential complications from epidural anesthesia include bizarre behavior (if the medication is injected into the circulation), increased length of labor, increased need for oxytocin, and shiver response. Urinary retention, not incontinence, is another possible complication.

While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include (Select all that apply): a. Culture. b. Anxiety and fear. c. Previous experiences with pain. d. Intervention of caregivers. e. Support systems.

ANS: A, B, C, E Culture: a woman's sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: extreme anxiety and fear magnify sensitivity to pain and impair a woman's ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. Support systems: an anxious partner is less able to provide help and support to a woman during labor. A woman's family and friends can be an important source of support if they convey realistic and positive information about labor and delivery.

The perinatal nurse explains to the student nurse that the effects of the H1 receptor antagonists include which of the following? (Select all that apply.) A. Block histamine action at the receptor sites B. Decrease nausea and vomiting C. Decrease anxiety and promote sleep or rest D. Lead to more efficient contractions earlier in labor E. May decrease fetal heart rate variability

ANS: A, B, C, E H1 receptor antagonists are medications that block the action of histamines at the receptor sites. These medications produce sedative, antiparkinsonian, and antiemetic effects. They cause drowsiness and are often used during early labor to promote sleep and to decrease anxiety. Phenothiazines specifically cross the placenta readily and may produce decreased fetal heart rate beat-to-beat variability.

Which of the following nursing actions can prevent or detect common side effects of epidural anesthesia? (Select all that apply.) A. Preloading the patient with a rapid infusion of IV fluids B. Continuing the patient on p.o. fluids only to prevent hypotension C. Monitoring the FHR for late deceleration and decrease in rate D. Use of intermittent FHR monitoring so the patient can use the birthing ball

ANS: A, C Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential.

The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis? (Select all that apply.) a. Assess leg movement and sensation before ambulating. b. Administer antibiotic as ordered. c. Observe for signs of impending birth. d. Provide sacral pressure as needed. e. Assess fetal position frequently.

ANS: A, C To prevent the risk for injury related to epidural anesthesia the nurse should asses for movement, sensation, and leg strength before ambulating, ambulate cautiously with an assistant, assist the woman to change positions regularly, and observe for signs that birth may be near: increase in bloody show, perineal bulging, and/or crowning.

The perinatal nurse is directing a student nurse in giving intravenous fentanyl citrate (Sublimaze) to a woman in labor. Which actions by the student would require the registered nurse to intervene? A. Administers the medication between contractions B. Administers the medication during a contraction C. Checks the three rights prior to administration D. Injects the medication rapidly E. Injects the medication slowly

ANS: A, C, D Sublimaze (and all opioid analgesics) should be administered during contractions so that the fetus has less exposure to the drug due to uterine vasoconstriction. There are five rights to medication administration (right patient, right drug, right dose, right route, right time). The medication should be injected slowly. The nurse should intervene if the student injects the medication between contractions, checks only three rights of medication administration, and injects the medication rapidly.

What assessment should be taken immediately after the anesthesiologist administers an epidural block to a laboring woman? a. Bladder for distention b. Blood pressure c. Sensation in the lower extremities d. Intravenous fluid flow rate

ANS: B Blood pressure is checked every 5 minutes when the epidural block is first begun. Bladder assessment is also important but not an initial assessment.

The nurse has presented a teaching session on pain relief options to a prenatal class. Which patient statement indicates that additional teaching is needed? A. "An epidural can be continuous or one dose." B. "General anesthesia is usually recommended for a patient who delivers by way of cesarean section." C. "Narcotics can be given through a patient's epidural infusion catheter." D. "A pudendal block usually works well to control pain during episiotomy repair."

ANS: B Compared to general anesthesia, spinal anesthesia is usually the anesthetic of choice indicated in the management of patients undergoing cesarean section. Epidural anesthesia can be administered in a single dose or via continuous infusion. To provide analgesia for approximately 24 hours after the birth, the analgesia provider may inject an opioid, such as morphine sulfate (Duramorph) or fentanyl (Sublimaze), into the epidural space immediately after the birth. A pudendal block technique is given in the second stage of labor for the provision of perineal anesthesia for the latter part of the first stage of labor, the second stage, birth, and episiotomy repair.

The patient at 39 weeks' gestation is undergoing a Cesarean birth due to breech presentation. General anesthesia is being used. Which potential challenge is most relevant to the anesthesia care of this patient? A. Hypotension due to the intense blockade of sympathetic fibers B. Difficulty with maternal intubation C. Broad ligament hematoma D. Fetal depression that is fetal depression inversely proportional to maternal anesthetic depth and duration

ANS: B Difficulty with maternal intubation is a primary challenge of general anesthesia care for pregnant patients. Regional anesthesia, including epidural anesthesia, is associated with an intense blockade of sympathetic fibers that results in a high incidence of hypotension. Broad ligament hematoma is a complication associated with pudendal blockade. Fetal depression associated with general anesthesia is directly proportional to maternal anesthetic depth and duration

The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief? a. Frequently asking for ice chips b. Facial grimacing c. Changing positions in bed d. Covering her face with her hands

ANS: B Facial grimacing may be an indicator of unexpressed pain.

A woman is preparing for whirlpool bath hydrotherapy. To ensure patient safety, what action by the nurse is best? A. Allow the woman to remain in the tub for no more than 20 minutes. B. Maintain water temperature no higher than 100.4°F (38°C). C. Obtain informed consent prior to allowing the woman in the tub. D. Use a wheelchair to transport the woman to the hydrotherapy tub.

ANS: B For safety, water temperature should remain between 96.8 and 100.4°F (36-38°C). The other actions are not necessary.

When caring for the laboring patient, the nurse determines that the fetus is located in the right occiput posterior (ROA). What will the nurse anticipate? a. Urinary retention b. Severe lower back pain c. A shorter labor process d. Nausea

ANS: B If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mother's sacrum, resulting in persistent and poorly relieved back pain (back labor). Labor is often longer with this fetal position.

A post-anesthesia care nurse is receiving a report on a patient who was delivered under general anesthesia. The operating room nurse states that the patient received a dose of metoclopramide (Reglan) IV in the operating room. The nurse explains to a student nurse the purpose of giving this drug is to do which of the following? A. Allow rapid anesthetic induction B. Increase the speed of gastric emptying C. Promote muscle relaxation D. Reduce stomach acid production

ANS: B Reglan increases the speed of gastric emptying, which helps prevent the aspiration of gastric contents. Pregnant women are at a higher risk of gastric reflux than the general population. Rapid induction is facilitated with a short-acting barbiturate such as thiopental sodium (Pentothal). Muscle relaxation can be facilitated with succinylcholine (Anectine). Ranitidine hydrochloride (Zantac) or cimetidine (Tagamet) can be used to decrease gastric acid production.

The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her baseline respiratory rate is 22 breaths per minute. What should be the patient's rate while performing slow breathing? a. 9 b. 11 c. 15 d. 20

ANS: B The range of respirations should be no lower than half of the base rate and no more rapid than double the base rate.

A nurse is coaching a woman in labor in patterned breathing. To use the slow-paced breathing method, which instruction is best? A. "Blow like you are blowing out a candle at the end of your breath." B. "I will count to 4 while you inhale and again when you exhale." C. "Take a deep cleansing breath when the contraction ends." D. "You need to breathe at half of your normal rate in this pattern."

ANS: B With the slow-paced breathing pattern, the woman first takes a deep cleansing breath, then breathes slowly in and out of her mouth at about half her normal respiratory rate. Her coach counts slowly to 4 during inhalation and again during exhalation. Blowing out the candle is an instruction given during transition with the pattern-paced method. The woman should begin and end each contraction with a deep cleansing breath. Telling the woman that her respiratory rate will be half of the normal rate does not provide any specific instruction for her to follow.

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure (Select all that apply)? a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase intravenous (IV) fluids. d. Administer oxygen. e. Perform a vaginal examination.

ANS: B, C, D Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. Placing the client in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure.

The OB clinic nurse is giving a pregnant woman information on different types of anesthesia and pain control for use during labor. What information does the nurse provide about spinal anesthesia block? (Select all that apply.) A. Anesthesia occurs after only a 10- to 15-minute delay. B. It can be used for both vaginal and cesarean births. C. It causes decreased maternal level of consciousness. D. It may increase the chance of an operative birth. E. It provides excellent muscular relaxation.

ANS: B, D, E Benefits of spinal block anesthesia include: easy to administer, has immediate onset of action, requires a smaller volume of medication, produces excellent muscular relaxation, allows for maintenance of maternal consciousness, and is associated with minimal blood loss. However, because the woman will lose the ability to feel contractions, maternal pushing efforts are compromised, which increases the risk of an operative birth.

While providing a hospital tour, the perinatal nurse shows the compact disc player stored in the birthing room. The nurse explains that music is encouraged during labor because it does which of the following? (Select all that apply.) A. Decreases the production of catecholamines B. Increases maternal distraction C. Increases maternal oxygen demands D. Increases the production of endorphins E. Increases the woman's ability to focus

ANS: B, D, E Music can help create a relaxing environment and boost spirits. During labor, music provides comfort and decreases maternal anxiety by stimulating the release of endorphins. Comforting music during labor promotes maternal relaxation, thereby increasing oxygen intake. Some women find that music enhances their ability to remain focused during contractions. Decreasing anxiety and pain will decrease oxygen requirements.

A laboring woman received an opioid agonist (meperidine) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate? a. Fentanyl (Sublimaze) b. Promethazine (Phenergan) c. Naloxone (Narcan) d. Nalbuphine (Nubain)

ANS: C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl, promethazine, and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Demerol on the neonate. Although meperidine (Demerol) is a low-cost medication and readily available, the use of Demerol in labor has been controversial because of its effects on the neonate.

The charge nurse is reviewing the plans of care for four laboring patients. Which care plan requires immediate reconsideration for revision? A. Administration of epidural anesthesia to a woman who is in the first stage of labor and has a shellfish allergy B. Administration of a spinal anesthetic to a woman who is scheduled for vaginal delivery of her baby C. Administration of epidural anesthesia to a woman with a history of vomiting secondary to hyperemesis gravidarum D. Administration of a spinal anesthetic to a woman with a history of irritable bowel syndrome (IBS)

ANS: C Contraindications to epidural anesthesia include severe hypovolemia of any etiology. This patient with hyperemesis gravidarum should be evaluated for severity of dehydration prior to administration of epidural anesthesia. A lumbar epidural relieves pain associated with the first and second stages of labor. An allergy to shellfish is not a contraindication to epidural anesthesia Spinal anesthetics may be used to provide anesthesia for cesarean birth and occasionally for vaginal birth. Irritable bowel syndrome (IBS) does not represent a contraindication to spinal anesthesia.

A nurse is caring for a pregnant woman scheduled to have an epidural block. The nurse reviews the woman's admission laboratory results and finds the following: white blood count (WBC) 6,500/ mm3, hemoglobin 14 mg/dL, hematocrit 38%, platelet count 98,000, and international normalized ratio (INR) 4.2. What action by the nurse is best? A. Document the findings in the woman's chart. B. Ensure a signed consent form is in the chart. C. Notify the health-care provider immediately. D. Start a peripheral IV of normal saline (NS).

ANS: C Contraindications to spinal/epidural blocks include maternal refusal, local or systemic infection, coagulopathies, actual or anticipated maternal hemorrhage, allergy to a specific agent being used, or lack of trained staff. This woman's platelet count is low and her INR is high, leading to concern about coagulopathies. The nurse should notify the health-care provider immediately. Documentation should always be thorough, but further action is needed. A signed consent form should be in the chart for an invasive procedure; however, this is not the priority at this point. An IV will probably be needed prior to delivery (depending on institutional protocol), but, again, this is not the priority in the setting of a patient with abnormal laboratory results.

A nurse is teaching a childbirth preparation class. The group is discussing individual expression of labor pain. What statement is accurate about a patient's expression of pain? a. It reduces the patient's perception of pain. b. It is intensified by the vertex position of the fetus. c. It is influenced by culture. d. It can be completely controlled by nonpharmacological techniques.

ANS: C Culture influences how women feel about birth and what is an acceptable response to pain.

A nurse receives a handoff report on a newborn who is jaundiced. The off-going nurse states that the mother received some sort of sedative during the intrapartum period. The nurse should check the mother's chart for what medication? A. Diphenhydramine (Benadryl) B. Hydroxyzine (Vistaril) C. Promethazine (Phenergan) D. Secobarbital sodium (Seconal)

ANS: C H1 receptor antagonists are often used for sedation and relaxation in labor. Promethazine binds to bilirubin binding sites and may cause hyperbilirubinemia and jaundice in term infants exposed to the drug during the intrapartal period. The other medications do not cause this side effect.

A patient in labor has internal fetal monitoring and normal vital signs. All fetal signs are reassuring. She wishes to try whirlpool bath hydrotherapy as a comfort measure. Which action by the nurse is best? A. Assist the woman into the tub so she doesn't fall. B. Ensure the water temperature does not exceed 101°F (38.3°C). C. Inform her that she is not able to participate in this method. D. Remove the fetal monitor wires prior to the patient's getting in the tub.

ANS: C Hydrotherapy can provide excellent comfort for many women in labor; however, the presence of internal fetal monitoring electrodes is a contraindication to the use of whirlpool tubs or jet hydrotherapy. The nurse should inform her of this and explore other comfort measures. The other options are not appropriate.

After receiving nalbuphine hydrochloride (Nubain), a woman's labor progresses rapidly, and the baby is born less than one hour later. The baby exhibits signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn? A. Fentanyl (Sublimaze) B. Butorphanol tartrate (Stadol) C. Naloxone (Narcan) D. Pentobarbital (Nembutal)

ANS: C Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain.

A woman is having a planned cesarean birth. The nurse explains to the student that which of the following would not be an appropriate choice of anesthesia for this woman? A. Epidural block B. General anesthesia C. Pudendal block D. Spinal block

ANS: C Pudendal block is considered a local/regional anesthesia and would not provide sufficient anesthesia for an operative birth. The other options are all appropriate.

The obstetric nurse is preparing the patient for an emergency cesarean birth, with no time to administer spinal anesthesia. The nurse is aware and prepared for the greatest risk of administering general anesthesia to the patient. This risk is: a. Respiratory depression. b. Uterine relaxation. c. Inadequate muscle relaxation. d. Aspiration of stomach contents.

ANS: D Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia; however, this can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.

Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions are experiencing more pain. d. Levels of pain-mitigating b-endorphins are higher during a spontaneous, natural childbirth.

ANS: D Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension.

Which method of pain management is safest for a gravida 3 para 2 admitted at 8 cm cervical dilation? a. Epidural anesthesia b. Narcotics c. Spinal block d. Breathing and relaxation techniques

ANS: D Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. It is unlikely that enough time remains to administer epidural or spinal anesthesia. A narcotic given at this time may reach its peak about the time of birth and result in respiratory depression in the newborn.

A woman is being prepared for an elective cesarean birth. The perinatal nurse assists the anesthesiologist with the spinal block and then positions the patient in a supine position. The patient's blood pressure drops to 90/52 mm Hg and there is a decrease in the fetal heart rate to 110 beats/minute. Which response by the nurse is best? A. Administer naloxone (Narcan) per protocol. B. Discontinue the patient's intravenous infusion. C. Have ephedrine ready for administration. D. Place a wedge under the patient's left hip.

ANS: D In the event of severe maternal hypotension, the nurse should place the patient in a lateral position or use a wedge under the hip to displace the uterus, elevate the legs, maintain or increase the IV infusion rate, and administer oxygen by face mask at 10 to 12 L/min, or according to institution protocol. Narcan is used to reverse the effects of opioids. Ephedrine would be the drug of choice for refractory hypotension if other measures don't work. The IV would not be discontinued.

The laboring patient requests pain medication. Her contractions are lasting 20-30 seconds and are occurring every 8-20 minutes. The nurse would explain that analgesics given at this time would likely cause: A. Fetal respiratory depression B. Decreased analgesic effectiveness at the end of labor. C. Maternal hypotension D. Prolonged labor.

ANS: D Pain medication given before labor becomes established is likely to prolong the labor process. Pain medication given before established labor does not cause fetal respiratory depression unless the mother delivers within an hour of receiving the medication. This is not likely if labor is not established. Medication given early in the labor process does not become less effective at the end of labor. Analgesics might lower the blood pressure, but this effect does not cause the contraction pattern to be altered

The perinatal nurse prepares to assess the labor of a patient who is in the triage area with her partner. She is contracting every 5 to 7 minutes and is very fearful about going home due to extreme fatigue and the distance to her house. The perinatal nurse determines that the patient is a fingertip dilated and50% effaced, and the cervix is anterior. The nurse might anticipate an order for what medication? A. Diphenhydramine (Benadryl) B. Lorazepam (Ativan) C. Promethazine (Phenergan) D. Secobarbitol sodium (Seconal)

ANS: D Secobarbital is the most commonly used barbiturate in labor. It is a fast-acting oral agent that produces mild sedation within 15 minutes following administration, and its effects last for 3 to 4 hours. For this woman, who is not yet ready for admission and exhausted, prescribed rest would be of benefit.

Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring patient in which of the following positions? A. On her right side in the center of the bed with her back curved B. Lying prone with a pillow under her chest C. On her left side with the bottom leg straight and the top leg slightly flexed D. Sitting on the edge of the bed with her back slightly curved and her feet on a stool

ANS: D Sitting on the edge of the bed with the back slightly curved and the feet on a stool allows the epidural spaces to be accessed more easily.

A patient has just been admitted for labor and delivery. She is having mild contractions every 15 minutes lasting 30 seconds. The patient wants to have a medication-free birth. When discussing medication alternatives, the nurse should be sure the patient understands that: A. In order to respect her wishes, no medication will be given. B. Pain relief will allow a more enjoyable birth experience. C. The use of medications allows the patient to rest and be less fatigued. D. The use of medications allows the patient to rest and be less fatigued.

ANS: D The decision not to medicate should be an informed one, and it is possible that the patient does not know about the effects pain and stress can have on the fetus. Once the effects are explained, it is still the patient's choice whether to receive medication.

A laboring patient requests hot and cold applications be applied to her abdomen for pain control. How will this intervention act to control pain? a. By increasing endorphin production b. By facilitating effacement and dilation c. By producing increasing pain tolerance d. By stimulation of large nerve fibers

ANS: D The gate control theory explains how pain impulses reach the brain for interpretation. It supports several nonpharmacological methods of pain control. According to this theory, pain is transmitted through small-diameter nerve fibers. However, the stimulation of large-diameter nerve fibers temporarily interferes with the conduction of impulses through small-diameter fibers. Techniques to stimulate large-diameter fibers and "close the gate" to painful impulses include massage, palm and fingertip pressure, and heat and cold applications.

The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery. What nursing action will be included in this plan to prevent the associated side effect of this type of anesthesia? a. Restrict oral fluids. b. Keep legs flexed. c. Walk with assistance as soon as possible. d. Lie flat for several hours.

ANS: D The woman would be advised to remain flat for several hours after the block to decrease the chance of postspinal headache.