Chapter 13: Promoting Patient Comfort During Labor and 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.

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 womans lower extremities prior to allowing ambulation. This action ensures patient safety. The other options are not related to ambulating after an epidural block.

The perinatal nurse explains to the new graduate nurse that fear and anxiety have physiological consequences in labor. The nurse is referring to what physiological process? A. Diminished effectiveness of contractions B. Faster, more intense labor and delivery C. Increased release of maternal endorphins D. More tissue trauma due to hurrying the delivery

ANS: A As muscle tension increases due to fear or anxiety, the effectiveness of uterine contractions decreases. Maternal pain is intensified. This leads to decreased labor progress.

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 womans 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 womans 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.

A woman received butorphanol (Stadol) IV for labor pain. Thirty minutes later, the patients respiratory rate is 8 breaths/minute. What action by the nurse is best? A. Administer naloxone (Narcan) per protocol. B. Call the perinatal rapid response team. C. Reduce the next dose of Stadol by half. D. Hold the next dose of Stadol and notify the provider.

ANS: A Butorphanol can cause both maternal and fetal respiratory depression. Naloxone is an opioid antagonist and will reverse the effects of opioids. This womans respiratory rate is too low, and the nurse needs to administer naloxone per protocol. There is no need to call a perinatal RRT prior to administering the medication. The patients medication regime should then be discussed with the provider.

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 patients 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 patients 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.

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.

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 perinatal nurse explains to the student nurse that which of the following may increase labor discomfort? A. Amniotomy B. Correct use of breathing methods C. Fetus in an occiput anterior position D. Positional changes during active labor

ANS: A Labor induction and augmentation, amniotomy, and vaginal examinations may be associated with intensifying labor discomfort. Amniotomy, which is the artificial rupture of the fetal membranes, may be performed using a plastic amnihook or surgical clamp. The occiput anterior position is the optimal position for the fetus. Proper breathing exercises and positional changes during labor facilitate comfort for the laboring woman.

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.

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 womans 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.

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.

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.

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.

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 100.4F (38C). 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 100.4F (3638C). The other actions are not necessary.

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.

A nursing instructor is explaining the differences between the somatic and visceral pain felt by women in labor to a class of nursing students. Which statement about these two types of pain is inconsistent with thorough knowledge of these two types of pain? A. Somatic pain is more intense, sharp, and burning. B. Somatic pain is usually only felt in the third stage. C. Visceral pain is most often felt during contractions. D. Visceral pain usually occurs in the first stage of labor.

ANS: B Somatic pain is sharp, intense, well-localized, burning, or prickling pain felt during the second stage of labor. It is caused by stretching of the perineal body, distention and traction, and soft tissue lacerations. Visceral pain is predominant during the first stage of labor. This deep, dull and aching, poorly localized pain is usually felt only during contractions.

The perinatal nurse observes a woman entering the transition phase of labor while she uses a patterned breathing method to cope with the increasing strength of contractions. She complains of light-headedness and tingling in her fingers. The most appropriate intervention by the nurse is to assist the patient in doing which of the following? A. Breathing more slowly and taking a cleansing breath B. Cupping her hands and breathing into them C. Putting her head between her knees D. Returning to bed and lying on her left side

ANS: B The symptoms of respiratory alkalosis are light-headedness, dizziness, tingling of the fingers, or circumoral numbness. Strategies to eliminate respiratory alkalosis focus on replacement of the bicarbonate ion by rebreathing carbon dioxide. This can be accomplished by instructing the woman to breathe into a paper bag held tightly around the mouth and nose or, if no bag is available, instructing her to breathe into her cupped hands.

The perinatal nurse is caring for a Native American woman in labor with her first baby. The patient asks about the possibility of burning sweet grass, a part of her cultural tradition, during labor. Which of the following is the best response by the nurse? A. Burning any type of substance is not allowed by policy in the hospital. Is there something else that I can do that would be similar? B. Can you explain to me a bit more about this custom and what it means to you so that I can understand it better? C. I need to confer with the charge nurse. I want to know if this practice can be allowed so I will ask to see if it is possible. D. I understand that this cultural practice is important to you; however, I am unable to accommodate your request at this time.

ANS: B When providing care, nurses must recognize that culture strongly influences how one perceives and copes with pain. Assessment of cultural beliefs and practices, questions to identify specific needs, and encouragement and support to use safe interventions is key in providing culturally sensitive care that empowers the patient to maintain her sense of control over her labor and childbirth experience. The nurse should make every attempt to accommodate this womans request as long as safety is not compromised. If the ritual is not permitted, the nurse can work with the patient to find an acceptable alternative. Using open-ended questions is preferable to yes-no questions for gathering information.

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.

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 womans fears? (Select all that apply.) A. Dont worry about the pain; at least its 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 its 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 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 womans 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 has the nursing diagnosis of fear related to incomplete childbirth education. What assessment would best indicate that actions to decrease fear have been successful? A. Better knowledge B. Chooses analgesia C. Decreased pain D. Increased pulse

ANS: C Anxiety and fear stimulate the release of catecholamines and heighten the sensation of pain. Decreased fear leads to relaxation and less pain. The other options do not show decreased fear.

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 womans urine output. Assessing vital signs and promoting bonding are important for all new mothers. Nurses should promote breastfeeding if this is the womans preference.

A nurse is caring for a pregnant woman scheduled to have an epidural block. The nurse reviews the womans 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 womans 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 womans 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 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 mothers 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 doesnt fall. B. Ensure the water temperature does not exceed 101F (38.3C). C. Inform her that she is not able to participate in this method. D. Remove the fetal monitor wires prior to the patients 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.

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.

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 complications.

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 Ringers (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.

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.

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.

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 patients 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 patients intravenous infusion. C. Have ephedrine ready for administration. D. Place a wedge under the patients 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 dont work. The IV would not be discontinued.

A patient in labor complains of a pain rating of 7 on a 1-to-10 scale. On assessing the patient further, the nurse finds her vital signs to be within normal limits, the patient is calm and cooperative, and she voided 400 mL 30 minutes ago. What action by the nurse is best? A. Delay treating the pain until physical signs are present. B. Reassess the woman in 1 hour for changes in vital signs. C. Tell her she can have medication when the pain is unbearable. D. Treat the womans pain according to the treatment plan.

ANS: D Quite simply, pain is what the patient says it is, and the nurse should treat this patient according to the treatment plan. Although there are objective signs that can be assessed with pain (changes in vital signs, emotional changes, and decreased urinary output), their absence does not invalidate the womans complaints.

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.

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. Patients 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 patients report of lessened pain is the most valuable assessment. During immersion, the maternal temperature and fetal heart rate should remain stable.