Chapter 16: The Nursing Role in Providing Comfort During Labor and Birth

1. How does a woman who feels in control of the situation during labor influence her pain? A) Feelings of control are inversely related to the client's report of pain. B) Decreased feeling of control helps during the third stage. C) There is no association between the two factors. D) Feeling in control shortens the overall length of labor.

Ans: A Client Needs: Psychosocial Integrity Cognitive Level: Understand Page: 376 Feedback: Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control.

9. Immediately following an epidural block, a woman's blood pressure suddenly falls to 90/50. The nurse's first action would be to: A) raise her head off the bed. B) ask her to inhale deeply at least five times. C) administer oxygen by facemask. D) turn her on her left side or raise her legs.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 384 Feedback: Turning her to her side or elevating her legs increases blood volume in her central body, thereby increasing blood pressure.

14. The nurse instructs the client about skin massage and the gate-control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods? A) The gate control mechanism is located at the pain site. B) Pain perception is decreased if anxiety is present. C) The gate control mechanism opens so all the stimuli pass through to the brain. D) This is a technique to prevent the painful stimuli from entering the brain.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 376 Feedback: Gate control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location.

28. A patient in labor with chronic back pain tells the nurse about taking a dose of hydrocodone/acetaminophen (Vicodin) for labor pain prior to coming to the hospital. What should the nurse prepare to do once the fetus is delivered? A) Evaluate the fetus for withdrawal symptoms. B) Inform the physician so that liver effects can be monitored. C) Suggest that no additional narcotic pain medication be provided during labor. D) Coach the patient in breathing techniques because other pain medication is contraindicated. E) Request that the physician prescribe the same medication to be used for pain during labor.

Ans: A, B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 393 Feedback: A typical prescription drug abused by women is hydrocodone/acetaminophen (Vicodin) because this is frequently prescribed for chronic back pain. The half-life of this drug is about 2 hours in addicted women. Even though it appears to have little effect on newborns, the newborn needs to be observed for both withdrawal and liver effects. The patient can receive other narcotic pain medication during labor. Other pain medication is not contraindicated for this patient. There are other, more safe pain medications that can be prescribed for the patient and fetus during labor.

27. The physician of a patient in labor decides that an emergency cesarean birth is required to safely deliver the fetus. When preparing the operating room suite for this procedure, which medications should the nurse ensure are available for possible use? Select all that apply. A) Diazepam B) Ephedrine C) Acetaminophen D) Atropine sulfate E) Lactated Ringer's solution

Ans: A, B, D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 387 Feedback: To ensure safe general anesthesia administration, specific drugs must be readily available, which include diazepam to control seizures, ephedrine to use if the blood pressure falls, and atropine sulfate to dry secretions and prevent aspiration. Acetaminophen and lactated Ringer's solution are not specifically identified for use using general anesthesia.

30. A pregnant patient received a narcotic analgesic 2 hours before delivery. The newborn is lethargic and difficult to arouse. What should the nurse prepare to do to help this newborn? A) Administer intravenous fluids. B) Apply oxygen and place in a heated bassinet. C) Administer naloxone hydrochloride. D) Provide tactile stimulation to encourage crying.

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 382 Feedback: Naloxone hydrochloride is a narcotic antagonist that counteracts the effect of narcotic analgesics. It is used to counteract respiratory depression in newborns when a woman has received a narcotic analgesic during labor. Intravenous fluids, oxygen, a heated bassinet, or tactile stimulation will not counteract the effects of a narcotic analgesic given before delivery.

6. Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? A) The father's coaching role may be disrupted at times. B) The infant may show increased drowsiness. C) The mother may have continued memory loss postpartum. D) The mother may have difficulty working effectively with contractions.

Ans: D Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 381 Feedback: Breathing and relaxation techniques can speed labor. An inability of the woman to do these as a result of pain relief measures can slow labor.

5. The injection of a local anesthetic to block specific nerve pathways is referred to as: A) amnesic medication. B) gas administration. C) natural anesthesia. D) regional block.

Ans: D Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Remember Page: 386 Feedback: Regional-block anesthesia successfully blocks pain sensation in a designated body part.

13. The following are nursing measures commonly offered to women in labor. Which nursing intervention probably would be most effective in applying the gate-control theory for relief of labor pain? A) Encourage the woman to rest between contractions. B) Change the woman's position. C) Give the prescribed medication. D) Massage the woman's back.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 379 Feedback: Gate control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area.

21. The nurse caring for pregnant patients is identifying interventions to support the 2020 National Health Goals regarding pain relief during labor. Which interventions support these goals? Select all that apply. A) Encourage pregnant patients to prepare for childbirth by attending classes. B) Discuss the advantages of using epidural or spinal anesthesia during labor. C) Review the various opioid analgesics that can be used to control the pain of labor. D) Review the different breathing techniques that help with pain control during labor. E) Explain the various complementary and alternative therapies to help with pain control.

Ans: A, D, E. Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 374 Feedback: Nurses can help the nation achieve the 2020 National Health Goals regarding pain relief during labor by educating women about the advantages of preparing for childbirth and helping them to use breathing patterns or other complementary and alternative therapies and techniques during labor so they need a minimum of analgesia and anesthesia. These goals would not be achieved by discussing the use of epidural or spinal anesthesia or by reviewing the various opioid analgesics available for use during labor.

7. A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse? A) "An injury is unlikely because of expert professional care given." B) "I have never read or heard of this happening." C) "The injection is given in the space outside the spinal cord." D) "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."

Ans: C Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 385-386 Feedback: An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.

17. A patient in labor is prescribed transcutaneous electrical nerve stimulation (TENS) to help with pain relief during labor. How should the nurse explain the process of pain relief with this method? A) Counterirritation stimulation blocks pain from traveling to the spinal cord. B) Needles are inserted along meridians to release endorphins and control pain. C) A machine is used to measure the patient's ability to relax during contractions. D) Small injections of sterile saline reduce are used to reduce the amount of back pain.

Ans: A Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 380 Feedback: Transcutaneous electrical nerve stimulation (TENS) works to relieve pain by applying counterirritation to nociceptors. Low-intensity electrical stimulation blocks the afferent fibers, preventing pain from traveling to the spinal cord synapses from the uterus. Needles being inserted along meridians to release endorphins explain acupuncture. A machine to measure the patient's ability to relax during contractions explains biofeedback. Small injections of saline to reduce back pain explain intracutaneous nerve stimulation.

18. The health care provider is reluctant to provide pain medication to a patient delivering a preterm fetus. What should the nurse explain to the patient as the reason for the preterm fetus being more affected by medication? A) Affinity of the preterm fetus to fat-soluble drugs B) Inability of the immature liver to metabolize or inactivate drugs C) Affinity of the preterm fetus to drugs that are strongly bound to protein D) Inability of the preterm fetus to use drugs with a molecular weight over 1,000

Ans: B Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 381 Feedback: A preterm fetus, which has an immature liver and is unable to metabolize or inactivate drugs, is generally more affected by drugs than a term fetus. A preterm fetus does not have an affinity to drugs that are fat soluble or strongly bound to protein. The preterm fetus is not able to metabolize drugs because of an immature liver, which has nothing to do with the molecular weight of the medication.

25. During labor, a pregnant patient's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective? A) The patient is not complaining of leg cramps. B) The patient is not requesting pain medication. C) The patient is focusing on a painting during contractions. D) The patient asks for a cold compress at the end of a contraction.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 377 Feedback: Touch and massage work to relieve pain by increasing the release of endorphins. Both techniques may also work because they serve as forms of distraction. Many women find massage helpful in the first and second stages of labor. The use of therapeutic touch and massage for the patient in labor is not used to reduce leg cramp. Focusing on a painting during contractions is a form of distraction. Asking for a cold compress at the end of a contraction is not directly related to the use of therapeutic touch and massage during labor.

23. A pregnant patient nearing her due date expresses anxiety over the labor and delivery process. Which outcome should the nurse select as appropriate for the patient during the delivery process? A) Patient requests pain medication throughout the labor process. B) Patient uses breathing techniques to control anxiety and pain during labor. C) Patient tolerates the use of sanitary napkins to absorb vaginal secretions during labor. D) Patient refuses complementary and alternative techniques to control pain during labor.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 388 Feedback: An outcome that indicates that the patient has less anxiety during labor and delivery would be the use of breathing techniques to control anxiety and pain during labor. Requesting pain medication, using sanitary napkins, and refusing complementary and alternative pain management techniques are not appropriate outcomes for labor and delivery.

26. A patient in labor who is dilated 7 cm reports that narcotic pain medication given 3 hours ago has worn off and is asking for another dose. How should the nurse respond to this request? A) "I will get permission from your doctor." B) "Your stage of labor makes giving another dose unsafe." C) "It is too early as the medication should be given only every 4 hours." D) "Since it has been over 3 hours, you should be able to have more of the medication."

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 381 Feedback: The timing of administration of narcotics in labor is especially important. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, narcotics are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth. The nurse does not need to get permission from the physician. Pain medication can be provided when needed and not on a set schedule of every 4 hours. The patient is nearing delivery so 3 hours from the last dose will not influence the decision to provide more medication.

22. The spouse of a pregnant patient is concerned about the risk of paralysis from an epidural block being used during labor. How should the nurse respond to the spouse's concern? A) "I have never read or heard of this happening." B) "The injection is given in the space outside the spinal cord." C) "An injury is unlikely because of expert professional care given." D) "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 384 Feedback: An anesthetic agent placed inside the ligamentum flavum in the epidural space is epidural anesthesia. An epidural is placed in the space at the L4-L5, L3-L4, or L2-L3 areas to block the spinal nerve roots in the space and the sympathetic nerve fibers that travel with them. The nurse should not minimize the spouse's concern because the nurse has never read or heard of this occurring. An injury can occur with any invasive procedure.

8. A woman refuses to have an epidural block because she does not want to have a spinal headache after birth. What would be the nurse's best response? A) "The anesthesiologist will do her best to avoid this." B) "The pain relief offered will compensate for the discomfort afterward." C) "Spinal headache is not a usual complication of epidural blocks." D) "Your health care provider knows what is best for you."

Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 386 Feedback: Because epidural anesthesia does not enter the cerebral spinal fluid space, it is unlikely to cause a "spinal headache."

15. The laboring client who is at 3 cm dilation and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice? A) This would cause fetal depression in utero. B) This may prolong labor and increase complications. C) The effects would wear off before birth. D) This can lead to maternal hypertension.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 376-381 Feedback: Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor.

29. A pregnant patient planning for labor is asking questions about pain control options. What should the nurse explain about pain control during labor? A) The physician will decide how much pain relief is needed during labor. B) Pain medication should be started immediately when contractions are thought to begin. C) Any medication should have maximum effect for the patient and minimal effect on the fetus. D) Any medication will interfere with the ability of the uterus to contract during labor and delivery.

Ans: C Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 381 Feedback: Any pain medication should have maximum effect for the patient and minimal effect on the fetus. The patient has the right to choose how much pain relief is wanted or used. Pain relief should be provided only after labor is well established. Medication should not interfere with the ability of the uterus to contract during labor and delivery. All medication does not interfere with this ability.

19. When teaching the pregnant patient about self-medicating for pain during labor, why did the nurse instruct the patient to avoid taking acetylsalicylic acid (aspirin)? A) Development of respiratory depression in the newborn B) Interference with the ability to concentrate on contractions C) Interference with blood coagulation with increased risk of bleeding in mother or infant D) Competition with bilirubin-binding sites in fetal circulation increases risk of kernicterus.

Ans: C Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 381 Feedback: The nurse should caution the pregnant patient not to take acetylsalicylic acid (aspirin) for pain in labor because aspirin interferes with blood coagulation, increasing the risk for bleeding in the newborn or patient. Aspirin does not cause respiratory depression in the newborn, interfere with contractions, or compete with bilirubin-binding cites in fetal circulation.

20. The nurse is preparing materials to instruct a pregnant patient about the use of a local anesthetic to block specific nerve pathways. About which type of pain reduction technique will the nurse instruct the patient? A) General anesthesia B) Pressure anesthesia C) Regional anesthesia D) Pudendal nerve block

Ans: C Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 382 Feedback: Regional anesthesia is the injection of a local anesthetic to block specific nerve pathways. This achieves pain relief by blocking sodium and potassium transport in the nerve membrane so the nerve is unable to conduct sensations. General anesthesia is rarely used and is not referred to as being general anesthesia. Pressure anesthesia results from the fetal head pressing against the stretched perineum. A pudendal nerve block is the injection of a local anesthetic through the vagina to anesthetize the pudendal nerve.

2. Transcutaneous electrical nerve stimulation (TENS) reduces pain by which of the following mechanisms? A) Efferent fibers are blocked by continuously applied high-intensity stimulation. B) Pain is prevented from traveling from the uterus to spinal cord synapses. C) Electrical impulses are created that interfere with nerve transmission. D) TENS reduces apprehension and thereby complements narcotic action.

Ans: C Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 380 Feedback: TENS therapy is similar to the process of gate control theory, meaning it interferes with transmission.

4. Why should a woman be cautioned against taking acetylsalicylic acid (aspirin) to relieve pain in labor? A) Competition with bilirubin-binding sites in fetal circulation increases risk of kernicterus B) Development of respiratory depression in the newborn C) Interference with blood coagulation with increased risk of bleeding in mother or infant D) Interference with the ability to concentrate on contractions

Ans: C Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 381 Feedback: Acetylsalicylic acid (aspirin) is documented to cause interference with blood coagulation.

11. A client who is in the transition phase reports her pain medication last given 3 hours ago has worn off. She asks if she can have another dose of the meperidine. How should the nurse respond to her request? A) "Since it has been over 3 hours, you should be able to have more of the medication." B) "It is too early as the medication should be given only every 4 hours." C) "Your stage of labor makes giving another dose unsafe." D) "I will get permission from your health care provider."

Ans: C Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 382 Feedback: Meperidine may cause CNS depression in the neonate if given too close to birth.

12. A woman is in labor with her second child. She knows that she will want epidural anesthesia, and she has already signed her consent form. What must the nurse do before the woman receives the epidural? A) Review the woman's medical history and laboratory results, and interview her to confirm all information is accurate and up to date. B) Place the woman in the fetal position on the table, and keep her steady so that she won't move during the procedure. C) Administer a fluid bolus through the IV line to reduce the risk of hypotension. D) Prepare a sterile field with the supplies and medications that will be needed.

Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Analyze Page: 384 Feedback: Epidurals can cause vasodilatation and result in hypotensive episodes. IV fluid bolus prior to epidural placement can help prevent the hypotensive episode.

16. When entering the second phase of labor, a patient tells the nurse that the pain is severe and is unsure if pain medication should be used. Which nursing diagnosis should the nurse use to guide the care of the patient at this time? A) Pain related to labor contractions B) Powerlessness related to the duration and intensity of labor C) Decision conflict related to the use of analgesia during labor D) Anxiety related to lack of knowledge about normal labor processes

Ans: C Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Page: 374 Feedback: The patient is in conflict regarding whether or not to use pain medication during labor at this time. This is an example of decisional conflict. The patient's need is much more than experiencing pain during labor contractions. There is no enough information to support that the patient is experiencing powerlessness. The patient is not demonstrating anxiety related to the labor process.

10. A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice? A) "That's wonderful. Medication during labor is not good for the baby." B) "Your health care provider is a man and has never been in labor; he may be underestimating the pain you will have." C) "I respect your preference whether it is to have medication or not." D) "Let me get you something for relaxation if you don't want anything for pain."

Ans: C Client Needs: Psychosocial Integrity Cognitive Level: Apply Page: 392 Feedback: Individualizing care to meet women's specific needs is a nursing responsibility.

3. Which of the following supports why a preterm fetus usually is more affected by medication given at birth than a full-term fetus? A) Affinity of the preterm fetus to drugs that are fat-soluble B) Affinity of the preterm fetus to drugs that are strongly bound to protein C) Inability of the preterm fetus to use drugs with a molecular weight over 1000 D) Inability of the immature liver to metabolize or inactivate drugs

Ans: D Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 381 Feedback: The liver of many full-term infants is not completely mature and is even less so in preterm infants.

24. Immediately following an epidural block, a pregnant patient's blood pressure suddenly falls to 90/50 mmHg. What action should the nurse take first? A) Place the patient supine. B) Raise the head of the bed. C) Ask the patient to take deep breaths. D) Turn onto the left side or raise the legs.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 384 Feedback: To help prevent supine hypotension syndrome, place the pregnant patient on the left side after an epidural block. If hypotension should occur, the patient's legs should be raised in addition to providing oxygen, intravenous fluids, and medication. The supine position encourages hypotension syndrome. Raising the head of the bed and deep breathing are not interventions to help with hypotension syndrome.