Chapter 17 OB

Which breathing techniques can be used by a pregnant client in labor to control pain during contractions? Slow-paced breathing Panting breaths Modified-paced breathing

386-387

A pregnant client is anxious about the pain that she may experience during labor. What does the nurse include in the prenatal teaching to relieve anxiety in this client? Explores different relaxation techniques

B 384

In the current practice of childbirth preparation, emphasis is placed on what? No specific method, but a variety of techniques

d 385

The nurse has administered lorazepam (Ativan) along with opioids to a client to relieve labor pain. Which sign in the client indicates a need for metoclopramide (Reglan)? Unrelieved pain

C 392

What are the causes of somatic pain in a client who is in the second phase of labor? pessure against the bladder Distention of the peritoneum Stretching of the perineal tissue

A,B,C 381-382

What precautions does the nurse take while providing care for a pregnant client during hydrotherapy? Maintain water temperature at 36° to 37° C. Assist the client while she gets in and out of the tub. Ensure that the water covers the client's abdomen.

A,B,D pg 389

The nurse is using heat and cold applications to reduce pain in a pregnant client during labor. What precautions does the nurse take? Ensures that heat and cold are used alternately Avoids hot or cold application over anesthetized areas Places two layers of cloth between the skin and the hot pack

A,C,E 388

A client is in active labor, with her cervix dilated to approximately 5 cm. She is beginning to tire and express discouragement. What can the nurse initiate to provide comfort and help reduce the risk of prolonged labor? Hydrotherapy

An active labor with dilation of approximately 5 cm will increase contractions and pain and tire the client, so hydrotherapy is initiated to provide pain relief and relaxation. Biofeedback may be helpful initially but the client may need pain medication if the pain increases. The primary health care provider may order spinal anesthesia in case the client has a cesarean birth. An intradermal water block is used to relieve lower back pain during labor. 389-390

The health care team is administering naloxone hydrochloride (Narcan) to a pregnant client in labor to counter the adverse effects of opioids. What does the nurse inform the client? "Naloxone will reverse the pain relief provided by the opioid."

B pg 395

The nurse is assisting a client in labor. What breathing pattern must the nurse remind the client to use when the contractions increase in frequency and intensity in the first phase of labor? Modified-paced breathing

During the first phase of labor, as contractions increase in frequency and intensity, the client must change breathing patterns to a modified-paced breathing technique. This breathing pattern is shallower and faster than the client's normal rate of breathing, but should not exceed twice the resting respiratory rate. Slow-paced breathing is performed at approximately half the normal breathing rate and is initiated when the client can no longer walk or talk through contractions. Patterned-paced breathing is suggested in the second phase of labor. It consists of panting breaths combined with soft blowing breaths at regular intervals. The patterns may vary; the 3:1 pattern is pant, pant, pant, blow and the 4:1 pattern is pant, pant, pant, pant, and blow. p. 387

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited.

The woman and her partner should experiment with massage before labor to see what might work best. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body. Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer. p. 388

With regard to what might be called the tactile approaches to comfort management, nurses should be aware of what? Hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited

The woman and her partner should experiment with massage before labor to see what might work best. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body. 388

The nurse is providing care for a pregnant client in labor. Which interventions does the nurse implement to improve the client's environment? Create a home-like setting. Provide space for movement. Facilitate easy access to showers.

384

With regard to breathing techniques during labor, maternity nurses should be aware of what? Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction

386

The nurse is caring for a Native-American client during labor. What does the nurse keep in mind about the client's cultural approach to pain? The client may use remedies from indigenous plants.

383

After delivering a healthy baby boy with epidural anesthesia, a woman on the postpartum unit complains of a severe headache. Which actions should the nurse anticipate in the woman's plan of care? Administering oral analgesics Assisting with a blood patch procedure Frequently monitoring vital signs

Conservative management for a PDPH includes administration of oral analgesics and methylxanthines (e.g., caffeine or theophylline). Methylxanthines cause constriction of cerebral blood vessels and may provide symptomatic relief. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for PDPH. Close monitoring of vital signs is essential. The nurse should suspect the client is suffering from a postdural puncture headache (PDPH). Characteristically, assuming an upright position triggers or intensifies the headache, whereas assuming a supine position achieves relief. p. 399

The nurse is caring for a client in the last trimester of pregnancy. What assessments will the client display related to the effects of fear and anxiety during labor? Increase in muscle tension

p. 383

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should do what? Help her breathe into a paper bag

387

The nurse is teaching pain relief techniques to a group of expectant clients. What does the nurse teach the clients about the gate-control theory of pain? Distractions block the nerve pathways.

383

What does the nurse teach a couple expecting their first child about the use of therapeutic touch (TT) to relieve pain during labor? TT uses the concept of energy fields within the body.

388

The nurse is teaching a couple about the use of imagery and visualization in managing pain during labor. What is the patient expected to do during this technique? Imagine breathing in light and energy. Imagine walking through a restful garden. Envisaging breathing out worries and tension

386

A pregnant client is experiencing somatic pain during labor that is intense, sharp, and burning. Which stage of labor is associated with this type of pain? Second

381

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is what? Counterpressure against the sacrum

383

Which condition often occurs in a nulliparous client in contrast with a multiparous client during labor? Greater sensory labor pain during easy labor

A nulliparous client may experience greater sensory labor pain during easy labor as compared to a multiparous client. This is because her reproductive tract structures are less flexible. The firmer tissues in nulliparous clients as compared to the flexible tissues in multiparous clients result in a gradual fetal descent. A nulliparous client has a longer labor and therefore experiences greater fatigue. A rapid fetal descent in the second stage of labor occurs in multiparous clients and causes greater sensory pain. STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, what day and time, and what material you will cover. p. 383

Which techniques can a pregnant client use to reduce her perception of pain during labor? Drinking herbal tea Reciting prayers Using attention-focusing techniques Using breathing techniques

A,B,D,E 386

Which techniques does the nurse use to comfort the pregnant client in the first stage of labor? Touch Effleurage Counterpressure

A,B,E 388

The nurse teaches the client nonpharmacologic pain management methods during a prenatal class. Which methods require practice for best results? Biofeedback Patterned breathing Controlled relaxation

A,C,D 385

With regard to systemic analgesics administered during labor, nurses should be aware that: effects on the newborn can include significant neonatal respiratory depression.

B 393

What intervention does the nurse perform to provide a relaxed environment for labor? Control sensory stimuli.

C 386

When caring for a client in the first phase of labor, the nurse observes that the client is experiencing visceral pain. In which area does visceral pain occur? Lower portion of the abdomen

D 381

Which factor is associated with the reduced pain and feelings of euphoria in a pregnant client during labor? Increase in beta-endorphin levels

D 382-383

With regard to systemic analgesics administered during labor, nurses should be aware of what? Effects on the fetus and newborn can include decreased alertness and delayed sucking

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. PCAs result in decreased use of an analgesic. 393

A pregnant client is extremely anxious during the labor process. Which condition does the nurse assess in the client that may occur due to anxiety? More catecholamine secretion

Excessive anxiety in the client increases catecholamine levels during labor, which increase the stimuli to the brain from the pelvis. This process decreases blood flow and magnifies pain perception. The client becomes more anxious and the effectiveness of uterine contractions decreases, ultimately slowing the progress of labor. A heightened sense of anxiety and fear also increases muscle tension, thereby increasing discomfort. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal. p. 383

A client is taking fentanyl citrate (Sublimaze) for labor pain. The nurse finds that the client has also been prescribed naloxone (Narcan) PRN. What is the purpose of naloxone? To reverse the central nervous system (CNS) depressant effects

Fentanyl citrate (Sublimaze) is a short-acting opioid narcotic agonist analgesic that may cause central nervous system (CNS) depression. Therefore, the nurse may need to administer naloxone (Narcan), an opioid antagonist that promptly reverses the CNS depressant effects. An opioid antagonist is helpful to relieve pain when a more rapid birth is anticipated. Opioids inhibit uterine contractions. Fentanyl citrate (Sublimaze) has a short duration of action, and more frequent dosing is required if the pain is not relieved in one dose. p. 395

With regard to spinal and epidural (block) anesthesia, nurses should know what? A high incidence of postpartum headache is seen with spinal blocks

Headaches may be prevented or mitigated to some degree by a number of methods. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for a spinal headache. 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. p. 399

What does the nurse teach the client about the benefits of breathing techniques in the second stage of labor? Causes increase in abdominal pressure

In the second stage of labor breathing technique is used to increase abdominal pressure and expel the fetus. In the first stage of labor, breathing helps to promote the relaxation of the abdominal muscles, thereby increasing the size of the abdominal cavity. This lessens the discomfort during contraction caused by the friction between the abdominal wall and the uterus. It also relaxes the muscles of the genital area and does not interfere with fetal descent. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know. p. 386

A woman in active labor receives an opioid agonist analgesic. 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? Meperidine (Demerol)

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 those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Nubain is an opioid agonist-antagonist analgesic. p. 393

Which factors contribute to an increase in a client's pain tolerance level? Use of relaxation techniques Desire for natural vaginal birth Quiet and relaxed ambience

Pain tolerance refers to the level of pain a laboring woman is willing to endure. The factors that influence a woman's pain tolerance level include desire for a natural vaginal birth, use of relaxation techniques for comfort, and the quiet and relaxed ambience during labor. If the client has reduced pain tolerance, the client is likely to ask for pharmacologic interventions for pain relief. Epidural analgesia is used to relieve pain experienced during natural vaginal birth. p. 382

What physiologic change can the nurse expect to see in the client during labor pain? Pallor and diaphoresis

Pallor and diaphoresis is commonly observed in clients during labor pain. Blood pressure tends to increase during labor. The client consumes more oxygen, leading to hyperventilation accompanied by respiratory alkalosis. The nurse must teach the client to perform rapid shallow breathing techniques during contractions. Intensifying pain may increase maternal heart rate during labor. STUDY TIP: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment. p. 382

A client is prescribed spinal anesthesia in preparation for a cesarean birth. The primary health care provider instructs the nurse to administer a preanesthetic fluid bolus. What is the purpose of this prescription? Prevent maternal hypotension

Spinal anesthesia may cause sympathetic blockade and increase the client's risk for hypotension. Therefore, the primary health care provider prescribes a preanesthetic fluid bolus 15 to 30 minutes before administering anesthesia. This will prevent hypotension in the client. There is no need to potentiate the effect of anesthesia, because the prescribed dose has optimum effect on the client. The nurse can maintain fluid balance by providing enough fluids to the client. There is a risk for neonatal hypoglycemia if the fluid bolus contains dextrose. p. 398

The nurse caring for a client in labor asks the support person to use heat application for pain relief. Why is heat applied to the body? To relieve general backache

The application of heat enhances relaxation and reduces pain during labor. Heat application is effective for general backache from fatigue or back pain caused by a posterior presentation. Cold applications, such as cold cloths, frozen gel packs, or ice packs, may be applied to relieve muscle spasms. Cold, not heat, is applied to the chest to increase comfort when the client feels warm. Neither heat nor cold should be applied over ischemic or anesthetized areas because tissues can be damaged. p. 388

During the prenatal assessment of a client, the nurse teaches the client about nonpharmacologic pain management. What does the nurse tell the client about this method? It provides the patient with a sense of control.

The client makes choices about the nonpharmacologic pain management methods that are best suited. This provides the client with a sense of control over childbirth. These measures are relatively simple and inexpensive. They do not require intensive training. However, the client may obtain best results from the practice. It can be used throughout labor. p. 384

What interventions does the nurse perform to provide emotional support to a client in labor? Compliment client efforts during labor. Use a calm, confident approach. Involve the client in care decisions.

The nurse must offer emotional support by complimenting the client and offering positive reinforcement for efforts during labor. The client must be involved in decision making regarding her own care. The nurse must use a calm and confident approach when assisting the client during labor. The nurse may offer food and nourishment, if allowed by the primary health care provider. The nurse must encourage participation in distracting activities and nonpharmacologic measures for comfort. p. 384

A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. What should the nurse's immediate response be? To help the woman breathe into a paper bag.

The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Telling her to breathe more slowly does not ensure a change in respirations. Turning her on her side will not solve this problem. Administration of a sedative could lead to neonatal depression because this woman, being in the transition phase, is near the birth process. The side-lying position is appropriate for supine hypotension. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice. p. 382, 387

The nurse is caring for a nulliparous client in labor. How is the experience for a nulliparous client different from that of a multiparous client? The nulliparous client experiences greater fatigue due to longer duration of labor.

383

The nurse is assisting a client who is prepared to use the paced breathing method. What does the nurse remind the client to do at the beginning of the breathing pattern? Take a deep relaxing breath.

387

During the second phase of labor the patient initiates pattern-paced breathing. What adverse symptoms must the nurse watch for when the patient initiates this method? Dizziness

The nurse must watch for symptoms of hyperventilation and resulting respiratory alkalosis. Symptoms of respiratory alkalosis during pattern-paced breathing include dizziness, light-headedness, tingling of fingers, or circumoral numbness. Pallor, nausea, and diaphoresis are generally observed in the active and transition phases of the first stage of labor. They are physiologic effects of pain. STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter. p. 387

The nurse is using pain-relief methods based in the gate-control theory of pain while assisting a pregnant client in labor. Which action by the nurse is in accordance with this theory? The nurse encourages the client to use imagery during labor.

According to the gate-control theory of pain, pain sensations travel to the brain along the sensory nerve pathways. However, only a limited number of pain sensations can travel at a time. The use of imagery during labor blocks the capacity of the nerve pathways to transmit the pain. Imagery helps close the hypothetic gate in the spinal cord and prevents pain signals from reaching the brain. Showering is not related to the use of the senses to achieve pain control. The use of opioid analgesic is a pharmacologic measure of relieving pain. The gate-control theory of pain is based on the use of sensory organs to relieve pain and does not depend on the adjustment of environmental factors like lights and noise. p. 383

A woman is experiencing back labor and complains of constant, intense pain in her lower back. What is an effective relief measure? Counterpressure against the sacrum

Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support. Test-Taking Tip: Do not read too much into the question or worry that it is a "trick." If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures. p. 387

Nurses should be aware of the difference experience can make in labor pain, such as what? Sensory pain for nulliparous women often is greater than for multiparous women during early labor.

Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue. Test-Taking Tip: Avoid choosing answers that use words such as always, never, must, all, and none. If you are confused about the question, read the choices, label them true or false, and choose the answer that is the odd one out (i.e., the one false one or the one true one). When a question is framed in the negative, such as "When assessing for pain, you should not," the false option is the correct choice. p. 383

After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: referred.

As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates in the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function. p. 381

What cultural beliefs must the nurse keep in mind when caring for a Chinese client in labor? The client may not exhibit reactions to pain. The client may refuse pain medication when it is offered the first time. The client may prefer acupuncture for pain relief.

The Chinese client may not exhibit reactions to pain, although exhibiting pain reactions during childbirth is acceptable. The nurse must offer pain interventions more than once, because the client may consider it impolite to accept something when it is first offered. The Chinese client generally prefers to use acupuncture for pain relief. Native-American clients may use medications or remedies made from indigenous plants. Hispanic clients may become vocal and request for pain relief late in labor. STUDY TIP: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation. p. 383