Maternity Ch. 14
During the vaginal examination of a laboring patient, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part? 1 2 cm above the ischial spine. 2 1 cm above the ischial spine. 3 at the level of the ischial spine. 4 1 cm below the ischial spine.
1 cm above the ischial spine. When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.
What care must the nurse take when implementing aromatherapy for a patient in labor? 1 Apply oil to the skin and massage. 2 Ask the patient to choose the scents. 3 Apply a few drops of oil to the hair. 4 Allow inhalation of warm oil vapors.
Ask the patient to choose the scents. Certain scents can evoke pleasant memories and feelings of love and security. So, it is helpful if the patient is allowed to choose the scents. The oils must never be applied in full strength directly on to the skin. Most oils should be diluted in a vegetable oil base before use. Inhaling vapors from the oil can lead to unpleasant side effects like nausea or headache. Drops of essential oils can be put on a pillow or on a woman's brow or palms or used as an ingredient in creating massage oil. It is not applied to the hair.
What intervention must the nurse perform while caring for a patient who is set to receive spinal anesthesia? 1 Assess maternal vital signs. 2 Monitor for signs of toxicity. 3 Keep side rails up on the bed. 4 Have oxygen readily available.
Assess maternal vital signs. The nurse must assess maternal vital signs, level of hydration, labor progress, and fetal heart rate (FHR) and pattern before the procedure is initiated. This helps to prepare for a possible emergency. When the procedure is initiated, the nurse ensures that oxygen and suction are readily available to ensure airway at all times. While the anesthesia is in effect, the nurse must monitor the patient for signs of toxicity and keep the side rails up on the bed to ensure patient safety.
What does the nurse teach the patient about the benefits of combining relaxation with walking, slow dancing, or rocking? This method may help: 1 Distract and divert from pain. 2 Increase abdominal pressure. 3 Manage stress throughout life. 4 The baby rotate through the pelvis.
Distract and divert from pain. When relaxation is combined with an activity such as walking, slow dancing, rocking, and position changes, it helps the baby to rotate through the pelvis. Simple relaxation exercises can help couples with the stresses of pregnancy, childbirth, and adjustment to parenting and can be a form of stress management throughout life. Breathing techniques provide distraction and diversion from pain. It helps to increase abdominal pressure in the second stage of labor and assists in expelling the fetus.
The nurse is teaching pain relief techniques to a group of expectant patients. What does the nurse teach the patients about the gate-control theory of pain? 1 Distractions block the nerve pathways. 2 Neuromuscular activity can increase pain. 3 All sensations travel together to the brain. 4 Motor activity during labor intensifies pain.
Distractions block the nerve pathways. The gate-control theory of pain explains the way pain relief techniques work to relieve the pain of labor. Distractions close down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. According to this theory only a limited number of sensations can travel through the sensory nerve pathways to the brain at one time. When the laboring patient engages in motor activity and neuromuscular activity, activity within the spinal cord itself further modifies the transmission of pain.
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? 1 Pallor 2 Nausea 3 Dizziness 4 Diaphoresis
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.
What intervention must the nurse perform for the patient demonstrating increased anxiety at the onset of labor? 1 Assess the blood pressure every 10 minutes. 2 Instruct the patient to use hypnosis to relieve pain. 3 Reassure the patient that an epidural will ease pain. 4 Encourage a support person to stay with the patient.
Encourage a support person to stay with the patient. The patient in labor prefers to have a familiar person to support during the labor process. The nurse must encourage the support person to stay with the patient. The nurse need not assess blood pressure every 10 minutes unless the patient is in severe distress. The patient can use hypnosis to relieve pain only if the patient has learnt and practiced the technique. The nurse must not encourage the patient to use an epidural unless the primary health care provider or the patient feels the need for the same.
What does the nurse ensure while following the procedure of the intradermal water block? 1 Administer the second injection after 15 minutes. 2 Ensure that a bleb appears on the skin after injection. 3 Inject in two locations on the lower back for pain relief. 4 Use a fine-gauge needle to inject 0.5 mL of sterile water.
Ensure that a bleb appears on the skin after injection. The nurse ensures that a bleb appears on the skin after the injection. An intradermal water block involves the injection of small amounts of sterile water (0.05 to 0.1 mL) by using a fine- gauge needle. Sterile water is injected into four locations on the lower back: two over each posterior superior iliac spine (PSIS) and two 3 cm below and 1 cm medial to the PSIS. The injections must be administered simultaneously to decrease the pain of the injections.
The nurse is caring for a patient who is administered local perineal infiltration anesthesia. In what situation does the nurse expect the use of local perineal infiltration anesthesia? When a(n): 1 Episiotomy is required. 2 Forceps birth is expected. 3 Cesarean birth is expected. 4 Vacuum extractor is to be used.
Episiotomy is required. Local perineal infiltration anesthesia may be used when an episiotomy is to be performed. It may also be used when lacerations must be sutured after birth in a patient who does not have regional anesthesia. Pudendal nerve block is administered late in the second stage of labor if an episiotomy is to be performed or if forceps or a vacuum extractor is to be used to facilitate birth. Low spinal anesthesia (block) may be used for cesarean birth.
The nurse is caring for a nulliparous patient in labor. How is the experience for a nulliparous patient different from that of a multiparous patient? The patient experiences: 1 Less sensory pain during early labor. 2 Greater sensory pain in the second stage of labor. 3 Greater fatigue due to longer duration of labor. 4 Greater affective pain in the second stage of labor.
Greater sensory pain in the second stage of labor. Parity influences the perception of labor pain. The nulliparous patient often has longer labor and therefore, greater fatigue. Sensory pain for nulliparous women is often greater than that for multiparous women during early labor, because their reproductive tract structures are less supple. Affective pain in the nulliparous patient is greater in the first stage as compared to a multiparous patient. It decreases for both patients during the second stage of labor. During the second stage of labor, the multiparous patient may experience greater sensory pain than the nulliparous patient. This is because tissues of the multiparous patient are more supple and increase the speed of fetal descent, thereby intensifying the pain.
Which condition would the nurse recognize as a contraindication to subarachnoid and epidural blocks? 1 Maternal hypertension 2 Maternal hypervolemia 3 Infection at injection site 4 Reduced intracranial pressure
Infection at injection site If the patient has an infection at the needle insertion site, subarachnoid or epidural blocks are contraindicated. Infection can spread through the peridural or subarachnoid spaces if the needle traverses an infected area. Maternal hypovolemia, not hypervolemia, leads to increased sympathetic tone to maintain the blood pressure. An anesthetic technique that blocks the sympathetic fibers can produce significant hypotension that can endanger the mother and fetus. Maternal hypotension, not hypertension, is contraindicated for anesthetic blocks. Increased intracranial pressure caused by a mass lesion is a contraindication for anesthetic blocks.
During the prenatal assessment of a patient, the nurse teaches the patient about nonpharmacologic pain management. What does the nurse tell the patient about this method? 1 It is technical and expensive. 2 It requires intensive training. 3 It provides the patient with a sense of control. 4 It is used only in stage I of labor.
It provides the patient with a sense of control. The patient makes choices about the nonpharmacologic pain management methods that are best suited. This provides the patient with a sense of control over childbirth. These measures are relatively simple and inexpensive. They do not require intensive training. However, the patient may obtain best results from the practice. It can be used throughout labor.
The nurse is assisting a patient in labor. What breathing pattern must the nurse remind the patient to use when the contractions increase in frequency and intensity in the first phase of labor? 1 Slow-paced breathing 2 Modified-paced breathing 3 3:1 pattern-paced breathing 4 4:1 pattern-paced breathing
Modified-paced breathing During the first phase of labor, as contractions increase in frequency and intensity, the patient must change breathing patterns to a modified-paced breathing technique. This breathing pattern is shallower and faster than the patient'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 patient 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.
The nurse is caring for a patient in the last trimester of pregnancy. What assessments will the patient display related to the effects of fear and anxiety during labor? An increase in: 1 Blood flow. 2 The progression of labor. 3 Contractions. 4 Muscle tension.
Muscle tension. Fear and excessive anxiety leads to increased muscle tension. It causes more catecholamine secretion. This increases the stimuli to the brain from the pelvis due to increased muscle tension and decreased blood flow. Thus fear and anxiety magnifies the perception of pain. Anxiety does not increase uterine contractions, but reduces the effectiveness of the contractions leading to increased discomfort. This slows the progress of labor.
The nurse is assisting a patient who is prepared to use the paced breathing method. What does the nurse remind the patient to do at the beginning of the breathing pattern? 1 Exhale a deep breath. 2 Take a deep relaxing breath. 3 Take 32 breaths per minute. 4 Take three breaths per minute.
Take a deep relaxing breath. The patient must remember that all breathing patterns begin with a deep, relaxing "cleansing breath" to "greet the contraction." The patient must then exhale a deep breath to "blow the contraction away." These deep breaths ensure adequate oxygen for the mother and the baby and signal that a contraction is beginning or has ended. The patient must take three to four breaths per minute when performing slow-paced breathing. As contractions increase in frequency and intensity, the patient takes shallow, fast breaths, about 32 to 40 per minute.
What intervention does the nurse perform while caring for a laboring patient who has been administered regional anesthesia? 1 Provide an indwelling urinary catheter. 2 Encourage the patient to void every 4 hours. 3 Ask the patient to void after receiving the block. 4 Position the patient supine in an upright position.
Provide an indwelling urinary catheter. A distended bladder can inhibit uterine contractions and fetal descent. This slows down the progress of labor. Therefore the nurse must provide an indwelling urinary catheter immediately after anesthesia has been initiated, and it must be left in place for the remainder of the first stage of labor. Spinal nerve blocks can reduce bladder sensation. Therefore the patient should empty the bladder before the induction of the block. The patient should be encouraged to void at least every 2 hours thereafter. The patient's position should be alternated from side to side every hour, so as to ensure adequate distribution of the anesthetic solution and to maintain blood circulation to the uterus and placenta.
What intervention does the nurse perform to provide a relaxed environment for labor? 1 Stand at the bedside. 2 Encourage rapid birth. 3 Control sensory stimuli. 4 Demonstrate excitement.
The nurse must assist the patient by providing a quiet and relaxed environment. A relaxed environment for labor is created by controlling sensory stimuli, such as light, noise, and temperature, as per the patient's preferences. The nurse must provide reassurance and comfort by sitting rather than standing at the bedside whenever possible. The nurse must not encourage or hurry the patient for rapid birth. The nurse must maintain a calm and unhurried attitude when caring for the patient.
The nurse is teaching a couple about nonpharmacologic pain relief measures during labor. What must the nurse tell the couple about the use of counterpressure? 1 The support person applies pressure to the sacral area. 2 The support person massages the patient's thigh or chest. 3 The technique brings relief during the first stage of labor. 4 The support person gently massages the patient's abdomen.
The support person applies pressure to the sacral area. Counterpressure is steady pressure applied by a support person to the sacral area with a firm object, such as a tennis ball or the fist or heel of the hand. Effleurage brings relief in the first stage of labor. Effleurage is light stroking or massaging of the abdomen, thigh, or chest, in rhythm with breathing during contractions. It is generally performed on the abdomen, but the presence of monitor belts makes it difficult to perform effleurage on the abdomen.
The nurse is teaching a class on childbirth. What does the nurse teach about signs of local anesthetic toxicity? Select all that apply. 1 Tinnitus 2 Metallic taste 3 Slurred speech 4 Long stage II labor 5 Increased use of oxytocin
Tinnitus Metallic taste Slurred speech The central nervous system can be affected if a local anesthetic agent is injected accidentally into a blood vessel leading to local anesthetic toxicity . Signs include metallic taste, tinnitus, and slurred speech. Longer stage II labor and increased use of oxytocin are side effects of epidural and spinal anesthesia.
The nurse caring for a patient in labor asks the support person to use heat application for pain relief. Why is heat applied to the body? 1 To relieve muscle spasms 2 To relax anesthetized areas 3 To relieve general backache 4 To provide comfort in the chest
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 patient feels warm. Neither heat nor cold should be applied over ischemic or anesthetized areas because tissues can be damaged.
The nurse is caring for a Native-American patient during labor. What does the nurse keep in mind about the patient's cultural approach to pain? The patient may: 1 Not exhibit reactions to pain. 2 Be vocal in response to pain. 3 Use remedies from indigenous plants. 4 Express pain vocally late in labor.
Use remedies from indigenous plants. The Native-American patient may use medications or remedies made from ethnic plants. They are often stoic in response to labor pain. Hispanic patients may be stoic until late in labor, when they may become vocal and request pain relief. Chinese patients may not exhibit reactions to pain. Arabian or Middle Eastern patients may be vocal in response to labor pain and request medication for pain relief.
A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's most appropriate analgesic for pain control is: 1 fentanyl (Sublimaze). 2 promethazine (Phenergan). 3 butorphanol tartrate (Stadol). 4 nalbuphine (Nubain).
fentanyl (Sublimaze). Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. 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. Its use may precipitate withdrawals in a patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use.
With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: 1 either hot or cold applications may provide relief, but they should never be used together in the same treatment. 2 acupuncture can be performed by a skilled nurse with just a little training. 3 hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. 4 therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations.
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.
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: 1 visceral. 2 referred. 3 somatic. 4 afterpain.
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 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.
Nurses should be aware of the difference experience can make in labor pain, such as: 1 sensory pain for nulliparous women often is greater than for multiparous women during early labor. 2 affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. 3 women with a history of substance abuse experience more pain during labor. 4 multiparous women have more fatigue from labor and therefore experience more pain.
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.