Pain Presentation
A nurse is teaching a client who is in labor about the use of nitrous oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching? A. "Nitrous oxide could make my baby sleepy when he is born." B. "I should inhale the nitrous oxide between contractions." C. "I will feel the effects of the nitrous oxide almost immediately." D. "Nitrous oxide can make me feel disoriented."
"I will feel the effects of the nitrous oxide almost immediately." The effects of nitrous oxide are felt within 1 minute of inhalation.
A nurse is caring for a client who is in labor and asks her partner to performs effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the client's partner? A. "Lightly stroke the upper thighs." B. "Steadily apply pressure to the sacrum." C. "Gently massage the mid-abdominal area." D. "Firmly squeeze both hips."
"Lightly stroke the upper thighs." Effleurage involves lightly stroking or massaging the abdomen in rhythm with breathing to help relieve labor pain. However, when a monitor belt is in use, the sides of the abdomen, chest, or upper thighs are alternative locations for massage.
A nurse is teaching a prenatal class about nonpharmacological comfort measures during labor. Which of the following statements should the nurse identify as an indication that the instructions have been understood? A. "I can have my partner apply counterpressure to my upper abdomen." B. "My baby will be monitored with a Doppler device during hydrotherapy." C. "I can have the nurse apply acupressure to my lower abdomen." D. "My TENS unit will not help with lower back pain during early labor."
"My baby will be monitored with a Doppler device during hydrotherapy." During hydrotherapy, the nurse should monitor the fetal heart rate with a fetoscope, a Doppler device, or a wireless external fetal monitor.
A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client? A. "This medication can cause your blood pressure to rise." B. "This medication can cause dry mouth." C. "This medication can cause you to urinate excessively." D. "This medication can make you sleepy."
"This medication can make you sleepy." Meperidine hydrochloride is an opioid analgesic used for moderate to severe pain during labor. The client should be informed of the possible adverse effects of this medication such as hypotension, confusion, sedation, headaches, respiratory depression, constipation, and urinary retention.
A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take? A. Assess the client's reflexes B. Assess the newborn for respiratory depression C. Assess the client for bradycardia D. Assess the newborn for signs of opiate withdrawal
Assess the newborn for respiratory depression Meperidine should not be administered to laboring clients who are expected to deliver within 4 hours of the medication administration. This medication crosses the placenta and causes respiratory depression in the newborn, which peaks in 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory depression caused by this medication.
A nurse is caring for a client in the latent stage of labor who is reporting a pain level of 4 on a scale of 1 to 10. Which of the following actions should the nurse take? A. Encourage the client to use hydrotherapy B. Teach the client biofeedback to control labor pain C. Lead the client in relaxation breathing techniques D. Administer a benzodiazepine medication
Lead the client in relaxation breathing techniques Relaxation breathing techniques in the first stage of labor promote relaxation of the abdominal muscles. This decreases discomfort and allows fetal descent. Hydrotherapy is recommended in the active stage. Pain medication usually for moderate to severe pain.
A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement first? A. Self-hypnosis B. Biofeedback C. Acupuncture D. Slow-paced breathing
Slow-paced breathing It is an easy technique for the client to learn quickly and practice immediately. It provides distraction, which can help reduce the perception of pain. The pattern is in 2-3-4/Out-2-3-4/In-2-3-4/Out-2-3-4. Repeating this cycle slows the client's breathing to about half of its usual rate, which can help relax the client and improve oxygenation.
A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block? A. Nausea and vomiting B. Tachycardia C. Hypotension D. Respiratory depression
Hypotension Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication.