Chapter 9: Pain Management during Labor and Birth

A woman's perception of pain can differ according to all of the following except:

the presentation, lie, and attitude of the fetus. Fetal position can influence a client's perception of pain. Fetal attitude does not influence a client's perception of pain.

Which is identified as the primary outcome for initiating comfort measures during the labor process?

Maintain the labor process All of the outcomes are accurate but the primary outcome is to maintain the labor process. By relaxing the mother, it is easier for her to work with her body and facilitate the labor process.

A client asks why she should learn breathing patterns for labor. After instruction is given, the nurse determines teaching has been effective when the client states:

"Breathing patterns are distraction techniques taught to decrease pain in labor." Breathing techniques are largely distraction techniques taught in birth classes and are well documented to decrease pain in labor.

Which client statement is anticipated after immediately receiving an intrathecal injection of pain medication?

"I have no pain now." The advantage of intrathecal medication administration is that the medication is effective almost immediately. The medication is placed in the subarachnoid space. The other options still have the client feeling some discomfort.

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best?

"The analgesia will reduce the sensation of pain for a limited period of time." It is best to prepare the client for the role of analgesia in her labor experience. It is best to explain that analgesia will reduce, not block or eliminate, the pain sensation for a limited period of time depending upon the medication selected. Stating the inability to get out of bed does not answer the client's question about pain relief.

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?

"The injection is given in the space outside the spinal cord." An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.

The nursing instructor is conducting a class discussion on the various agents used during labor and delivery to assist the client. The instructor determines the class is successful after the students correctly choose which factor as true about the use of systemic analgesia?

Benzodiazepines enhance pain relief attained with opioids and cause sedation. Barbiturates are used in latent labor for their minor tranquilizing and sedative effects. They can also be used just before general anesthesia, if required. Ataractics are opioid agonists used to decrease anxiety, nausea, and vomiting. Opioids may be given IV, intrathecally, or epidurally.

Prior to infusing medication into an epidural catheter inserted into a laboring mother, which vital sign is a priority?

Blood pressure Once the epidural catheter is inserted, blood pressure readings are obtained by the nurse every 3 to 5 minutes due to the potential side effect of hypotension. The other options are important to assess but not as directly related to the epidural or as important to monitor as the blood pressure.

The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?

Continue with the admission assessment The nurse should continue with the assessment to establish a baseline for the client and determine her status. This could include asking any personal questions that might be inappropriate to ask in front of the doula. Doulas are birth coaches who provide one-on-one support in labor and throughout birth. A doula does not take the place of a nurse or client's partner but is there to assist in the process. There would be no need to print off any instructions for the doula to sign.

The nurse is caring for a laboring client who has been administered a regional block for pain management. What is the nurse's priority action?

Ensure that emergency equipment is readily available Emergency equipment must be kept at hand when a client receives regional anesthesia. A side-lying position is unnecessary and nausea is not a common adverse effect. Pain assessment should be more frequent than every 20 minutes.

How does a woman who feels in control of the situation during labor influence her pain?

Feelings of control are inversely related to the client's report of pain. 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.

Why should a woman be cautioned against taking acetylsalicylic acid (aspirin) to relieve pain in labor?

Interference with blood coagulation with increased risk of bleeding in mother or infant Acetylsalicylic acid (aspirin) is documented to cause interference with blood coagulation.

The nurse is assessing the client who received spinal anesthesia to deliver a healthy fetus. In reviewing the family history, malignant hyperthermia is noted. If noted in the client, which early symptom will the nurse notify the health care provider about immediately?

Muscle rigidity Early symptoms of malignant hyperthermia include muscle rigidity, tachycardia, irregular heart rhythm, decreased oxygen saturation, and cyanosis. An elevated temperature is a late sign.

The nurse is preparing to administer an intradermal water injection to a client who is in labor. Which action should the nurse prioritize?

Prepare four 1 mL syringes of 0.05 to 0.1 mL sterile water using a 25 gauge needle. Intradermal water injections are effective in relieving back pain for 45 to 120 minutes (not abdominal pain or every 15 to 20 minutes). They are given into the intradermal space on the lower back as four separate injections of 0.05 mL to 0.1 mL sterile water using a 1 mL syringe with a 25 gauge needle. These may be repeated as needed.

There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain?

Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. Research has shown that women report higher levels of satisfaction with their labor experience when they feel a high degree of control over the experience of pain (Stuebe & Barbieri, 2005).

All pain management modalities can slow labor if given too early except:

acupuncture Acupuncture can be used to augment labor. Epidural anesthesia and narcotics such as meperidine and butorphanol can slow labor progress if given too early.

The nurse has just administered morphine 2 mg IV to a laboring client. Which change in the fetal heart rate pattern would the nurse prioritize?

decreased variability Decreased variability (not increased) is a common side effect when opioid analgesics, such as morphine, are used. Early decelerations are gradual decreases in the FHR that mirror the contraction. Late decelerations indicate uteroplacental insufficiency and are not related to opioids.

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using?

effleurage Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation.

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:

effleurage. Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain.

A client receives an epidural anesthetic. Which medication would the nurse anticipate the primary care provider will prescribe if the client develops moderate hypotension?

ephedrine A hypotensive agent such as ephedrine is given to elevate blood pressure if hypotension occurs.

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?

respiratory depression Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural puncture (spinal) headache are all side effects of a spinal epidural block.

There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration?

It can be administered by the nurse. Opioids can be given by the nurse and are most frequently given by the intravenous (IV) route because this route provides fast onset and more consistent drug levels than do the subcutaneous or intramuscular routes. Fetal risks exist, and fetal monitoring cannot necessarily be discontinued once the client receives opioids.

The nurse is assisting a health care provider in inserting an epidural into a laboring mother. Completion of which nursing task helps prevent maternal hypotension?

Priming tubing for initiating a fluid bolus Priming tubing for a fluid bolus is helpful in preventing maternal hypotension secondary to epidural placement. Introducing fluid to the vascular space elevates the circulating volume and blood pressure. Patterned breathing helps to promote relaxation but does not influence hypotension. Elevating the client's legs assists in returning the blood to the heart. This may be helpful but not as helpful as the fluid bolus. Vasopressors are not administered during labor. Fluid is completed before medication would be introduced into the system.

Which medication is administered to reverse the depressant effects of opioids?

naloxone Naloxone is an opioid antagonist. Butorphanol, nalbuphine, and meperidine are opioids.

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?

Decision conflict related to the use of analgesia during labor 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.

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?

"Your stage of labor makes giving another dose unsafe." 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.

A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:

"I may end up with a severe headache from the spinal anesthesia." Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating pain from a postdural puncture (spinal) headache.

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?

"I respect your preference, whether it is to have medication or not." Individualizing care to meet a woman's specific needs is a nursing responsibility.

A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response?

"Spinal headache is not a usual complication of epidural blocks." Because epidural anesthesia does not enter the cerebral spinal fluid space, it is unlikely to cause a "spinal headache."

When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies?

"Tell me how you handled labor pain in your past deliveries." When the nurse is collecting data, it is best to discuss previous experiences with labor pain. Other questions may include, "What was helpful?" or "What did you not like?" While it is true that every labor is different, understanding the client's perspective from past experiences is valuable in developing individualized strategies. Developing a plan is best as a collaborative effort, not by picking pre-prepared options. It is important to include a support person if desired.

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 the request?

"Your phase of labor makes giving another dose unsafe." Meperidine may cause central nervous system depression in the neonate if given too close to birth. This client is in the transition phase, thus, is within 30 minutes to 2 hours of birth. Whether it has been 3 or 4 hours since the last dose is not the determining factor; safety is the determining factor. There is no need to ask the health care provider.

A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. The timing of administration of narcotics in labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. 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.

In providing culturally competent care to a laboring woman, which is a priority?

Identify how the client expresses labor pain. Pain is a part of the labor process and management of the pain impacts the labor process itself. The nurse must effectively be able to assess the client's pain level to be able to provide care. Individuals from different cultures express pain in different ways. All of the other options are important to understand but they do not directly relate to the client and birth process.

The nurse is caring for a client who appears tense and apprehensive as labor progresses. Which nursing intervention is most helpful?

Initiate comfort measures Initiating comfort measures allows the tense client to relax which may decrease anxiety and apprehension. Comfort measures can include a variety of interventions such as ice chips, lip balm or touch, massage, and acupressure. This interaction between the nurse and client also conveys a caring, supportive attitude. This establishes a trusting relationship which again decreases anxiety. All other options are appropriate but not as helpful personally to the client in labor.

A 21-year-old G1P0 was admitted four hours ago in labor and she is now requesting an epidural. Which nursing action should the nurse prioritize for this client?

Insert an IV line and administer a 500 mL bolus of Ringer's lactate. To reduce the risk of hypotension, it is important for the woman to be well hydrated. This is accomplished by administering a bolus of 500- to 2,000-mL IV fluid. Inserting an IV line and administering an IV bolus such as with Ringer's lactate solution are the only appropriate nursing interventions. The nurse can answer questions and explain the procedure; however, the anesthesiologist will obtain consent, prepare the sterile field, and clean the patient's back. Vasopressors are not routinely ordered for an epidural procedure and are used only if the patient develops hypotension.

A nurse is meeting with a client to develop the nursing care plan for her delivery to include the use of an injectable pain medication. When comparing the various options for the client, which advantage of using an intrathecal anesthesia over an epidural anesthesia should the nurse point out?

Intrathecal anesthesia is a simpler technique providing quicker pain relief than epidural anesthesia. Onset of intrathecal (spinal) anesthesia is immediate. Epidural anesthesia can take 15 to 30 minutes to provide pain relief. Epidural anesthesia can be given in a continuous dosage; spinal anesthesia is given as a one-time injection that can wear off before delivery, thus requiring some form of additional pain medication. Both epidural anesthesia and spinal anesthesia can cause hypotension. Both can be modified to effect mobility, allowing the woman to be able to ambulate.

Which nursing suggestions are options for the client experiencing intense pain in the active phase of labor? Select all that apply.

Patterned breathing Hypnosis Pain medication Massage Acupressure Depending upon the client's labor plan and the preparation she and her partner have received prior to the labor experience, patterned breathing, hypnosis, pain medication, massage and acupressure are all options to improve relaxation and pain management. Effleurage is also a technique used in pain management; however, it is only used in the early phase of labor.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?

The mother may have difficulty working effectively with contractions. 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.

During labor, a pregnant patient's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective?

The patient is not requesting pain medication. 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.

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?

Regional anesthesia 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.

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?

Respiratory status Opioids like fentanyl have significant effects on the client's respiratory status. This is the priority assessment because the other parameters are affected to a lesser degree.

The postpartum nurse is providing care for a client who has just given birth and had epidural anesthesia. Her vital signs are stable, her pain is a 3 on a scale of 0 to 10, and she states that she is tired. The feeling in the client's legs has returned, but she cannot lift her knees, and she has not been out of the bed. What is the most appropriate nursing diagnosis to include in the plan of care at this time?

Risk for Injury Because the client had epidural anesthesia, cannot lift her legs, and has not been out of the bed since the epidural, she is at risk for injury. The nurse should take all measures to make her safe because walking may be difficult for her at first. There is not enough substantial evidence to support the other nursing diagnoses at this time.

Which order by the health care provider would the nurse question if given in the active stage of labor?

Secobarbital for relaxation A sedative, such as secobarbital, is given in early labor to promote sleep or a hypertonic contraction pattern. This class of barbiturates can cause respiratory and central nervous system depression if given within 12 to 24 hours of birth. Ice chips may be provided to decrease symptoms of dry mouth. Providing client positioning with the use of pillows for support may allow the client to relax between contractions. For safety reasons, primarily during an intense contraction, the client needs assistance while out of bed.

The nurse is discussing options to provide relief of labor pain when the client states, "Why can't the health care provider provide a sedative during labor?" Which disadvantages are common with providing a sedative as pain management? Select all that apply.

Sedatives will not provide pain relief. The sedation effect can cross to the fetus. Sedatives are only used in early labor Sedatives are used in the early stage of labor to promote sleep, not restlessness. Sedation does not extend to the delivery period as other medications are used in active labor. Disadvantages of using sedatives are as follows: they do not provide pain relief, they can pass to the fetus, and they are not used throughout the labor process.

A primigravida is 1 cm dilated, in early latent labor, and interested in avoiding epidural anesthesia. After asking about which nonpharmacologic options for pain relief she can use at this time, which option(s) should the nurse point out to the client? Select all that apply.

Simple breathing exercises Effleurage Walking and then using a birthing ball Simple breathing exercises, effleurage, walking, and using a birthing ball are all techniques which have been effective in the early stages of labor to help the client cope with the pain and avoid pain medication, especially epidurals. It is not too late to use nonpharmacologic measures and, in fact, this is the best time to use them. It is too soon for hydrotherapy and it could actually slow down the labor process. It is best if this is used after the woman has dilated to 5 cm.

A laboring client is restless and moving frequently in the bed. She appears to be more uncomfortable with the contractions but refuses pain medication when offered. The client's partner has left the room to stretch his legs. Which response by the nurse is most helpful?

Stand next to the client at the side of the bed. The client is alone and progressing well in labor as evidenced by her restlessness. She is refusing analgesia but will benefit from awareness that the nurse is attending her at the bedside and that she is not alone. Standing behind her will not provide a sense of nursing presence. Turning up music or turning on the television is not appropriate unless the client requests them as distractions.

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

maternal hypotension and fetal bradycardia Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. The other choices are not an adverse effect of epidural anesthesia.

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?

meperidine Meperidine is an opioid that is commonly used during labor and birth. Secobarbital and thiopental are barbiturates. Hydroxyzine hydrochloride is a tranquilizer which can be used to supplement the narcotic or reduce anxiety.

A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication?

naloxone Naloxone is the drug used for reversal of opioids' adverse effects. If a narcotic is given too close to birth, the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered (respiratory depression, sleepiness) in the fetus for 2 to 3 hours after birth. Indomethacin is an analgesic and NSAID; ampicillin is an antibiotic; and epinephrine is a vasopressor.

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?

starting an IV and hanging IV fluids Prehydration with IV fluids helps to prevent the most common side effect of epidural anesthesia, which is hypotension (20%). If the client develops hypotension or respiratory depression, then IV ephedrine or IV naloxone, respectively, can be administered, but neither is preventive. Maintaining the client in a supine position is recommended for a spinal headache, which can be a side effect of epidural anesthesia but is not the most common side effect and is not preventive.

Immediately following an epidural block, a woman's blood pressure suddenly falls to 90/50. The nurse's first action would be to:

turn her on her left side or raise her legs. Turning her to her side or elevating her legs increases blood volume in her central body, thereby increasing blood pressure.

A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication?

uterine atony A complication of general anesthesia is the relaxation of the uterine muscles, leading to uterine atony and possible postpartum hemorrhage. Maternal hypotension, a failed block, and pruritus are side effects of epidural analgesia.

The health care provider and nurse are assisting the client in the delivery of the fetus. The mother has been pushing with little effect. As the nurse obtains the instruments to assist with delivery, which method is used for pain relief?

A pudendal block A pudendal block is given just before the baby is born to provide pain relief for birth. Given at this time, the pudendal block does not impact the client's ability to push (which can prolong the labor). This block is also effective for births that require instruments to deliver the baby or complete an episiotomy. Though IV pain medication is rapid acting, it is not the analgesia of choice at this time. General anesthesia is used in emergency situations when the baby has to be delivered quickly. An epidural is for pain relief through the labor process.

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?

Administer naloxone hydrochloride. 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.

A pregnant patient planning for labor is asking questions about pain control options. What should the nurse explain about pain control during labor?

Any medication should have maximum effect for the patient and minimal effect on the fetus. 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.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?

Assess fetal heart rate. After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier and affect fetal heart rate and variability. After birth, there may be a decrease in alertness of the neonate. Maternal factors of decreased blood pressure, constipation, and dry mouth are of a lower priority.

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?

Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. In a pregnant woman, hypotension is best managed in the left lateral or semi-Fowler position owing to the risk of supine hypotension in the supine position and in Trendelenburg position. The sitting position could exacerbate hypotension. Naloxone is administered for respiratory depression. When the mother experiences a change in vital signs, this may affect the fetal heart rate.

The nurse is caring for a client experiencing pruritus secondary to opioid medication administration during labor. When reviewing the medication administration record, which medication would the nurse offer the client?

Diphenhydramine Diphenhydramine is an antihistamine which would be helpful to the client experiencing pruritus as a side effect of opioid medication administration. Meperidine is another opioid analgesic. Both naloxone and nalbuphine are opioid antagonists.

A gravida 3 para 2 client has been in labor for 4 hours and is experiencing severe back pain with each contraction. She is extremely uncomfortable and distressed because she never had this type of pain with her other labors. Which intervention can the nurse point out is best for this client to try to address her pain?

Effleurage Effleurage or massage would be an appropriate technique to use at this point. It is used as a distraction and relaxation technique. It increases the production of endorphins which reduce the transmission of signals between nerve cells and thus lower the perception of pain. Imagery is another technique but may not be as effective for relieving the pain if it is intense. A change of position may help with the pain as the woman finds a position of comfort, lying still may not be effective. The use of oral pain medication presents a danger to the fetus depending on what is used as it can pass through the placenta and adversely affect the heart and lungs of the fetus.

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.

Encourage pregnant patients to prepare for childbirth by attending classes. Review the different breathing techniques that help with pain control during labor. Explain the various complementary and alternative therapies to help with pain control. 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.

Which nursing intervention best aligns with the priority NANDA nursing diagnosis: Readiness for Enhanced Knowledge?

Encourage prenatal class attendance. A client who is prepared for the labor process by attending prenatal classes better can cope with the stress of labor. Identifying the priority nursing diagnosis of Readiness for Enhanced Knowledge suggests that the client and possibly support person are ready to learn about childbirth. Both the client and support person need instruction on relaxation techniques. A thorough obstetric history provides an understanding of the client's past for the nurse. Providing verbal cues is not as effective as attending prenatal classes.

The nurse is caring for a client who is diagnosed with a postdural puncture (spinal) headache. When completing a nursing assessment, which position would exacerbate the symptoms?

Fowler position A postdural puncture (spinal) headache occurs when the client is in an upright position and is relieved when the client is laying down and still. The nurse is correct to avoid placing the client in the Fowler or upright position. The other positions may be attempted to assess client symptoms.

Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation?

General General anesthesia is reserved for emergencies in which the fetus must be delivered immediately to save the life of the fetus, mother or both. Regional anesthesia provides pain relief during labor and birth. Local anesthesia is typically a short-acting anesthesia used to numb the perineum.

A client in labor receiving epidural anesthesia develops hypotension. Which of the following would the nurse do first?

Give an intravenous bolus of fluid On detecting maternal hypotension as a result of epidural anesthesia, the nurse should administer a bolus of IV fluid to the client. This generally raises the BP to normal. If this is ineffective, the nurse should consider injecting ephedrine to raise the BP only after notifying the anesthesiologist and receiving an order for the drug. There is no need to call the anesthesiologist immediately. Injection of propranolol will decrease the BP further and is not recommended.

The nurse is preparing a client in labor to receive a pudendal block with lidocaine. The nurse would place the client in which position for administration?

Lithotomy Pudendal anesthesia is typically administered to anesthetize the lower vagina, vulva, and perineum. The obstetrician or certified nurse midwife injects the anesthetic agent, such as lidocaine, through the lateral vaginal walls into the area near both the right and left pudendal nerve behind the sacrospinous ligament at the level of the ischial spines. The injection is made through the vagina with the client in lithotomy or dorsal recumbent position. The left lateral, prone or Trendelenburg positions would be inappropriate.

Which nursing assessments are most important following epidural catheter removal in the postpartum period? Select all that apply.

Lower extremity motor function Sensation below hips Urinary status The epidural catheter used for pain relief is no longer needed following birth or possibly a tubal ligation. Nursing assessments must include lower extremity functioning with sensations below the hips, not above, to see the neural transmission return. Assessment of the urinary status is needed as urinary retention can occur. The gastrointestinal status is not impacted.

When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful?

The characteristics of labor pain follow a pattern. While pain is individualized, labor pain is defined and follows a pattern. Since it follows a typical path, education and planning is completed. All pain is not the same. A primigravid needs education and guidance to best navigate the process. A cesarean section is not an option as a method of pain management.

The pain of labor is influenced by many factors. What is one of these factors?

The woman is prepared for labor and birth. The woman who enters labor with realistic expectations usually copes well and reports a more satisfying labor experience than does a woman who is not as well prepared.

The laboring client who is at 3 cm dilation (dilatation) 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?

This may prolong labor and increase complications. 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.

The nurse is correct to instruct the client in active labor on which type of patterned breathing?

Transitioning breaths from "slow, deep breaths to quicker short breaths" at the contraction peak. A client who is in active labor varies her breathing technique to modified-paced breathing, which alters between slow, deep breaths to shorter and quicker breaths at the contraction peak. Slow-paced breathing is for early labor and focuses on relaxation. Short, quick breaths are used with more intense and frequent contractions. The client should not hold her breath until pushing begins.

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?

acupressure Acupressure is the application of pressure or massage at designated susceptible body points. A common point used for a woman in labor is Co4, which is located between the first finger and thumb on the back of the hand. Women may report their contractions feel lighter when a support person holds and squeezes their hand because the support person is accidentally triggering this point. Acupuncture involves insertion of needles into the same body points. Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for birth classes, is a classic example of therapeutic touch. Biofeedback is based on the belief that people have control and can regulate internal events such as heart rate and pain responses.

A laboring client has recently received intrathecal anesthesia for the treatment of pain. When monitoring the client for common adverse effects of this treatment, the nurse should prioritize:

blood pressure monitoring. Hypotension is the most common adverse effect of epidural anesthesia; decreased respiratory rate and heart rate disturbances are less common. Pain is the indication for treatment, not an adverse effect.

The nurse is working with a client approaching her due date. Arrange the sequence of typical labor pain that the client may experience from onset to birth of the fetus. Use all options.

cramping in the lower abdomen pain in the lower back, buttocks and thighs strong contractions resulting in fetal movement intense burning and stretching pain in the perineum A typical progression of labor pains occur as a result of maternal adaptation to the labor process and the fetus moving down the birth canal. Cramping noted in the lower abdomen is generally the first indication of labor. This cramping occurs from the stretching required to efface and dilate the cervix. Cramping progresses to labor pain located in the lower back, buttocks and thigh. Intense contractions as labor continues occurs in waves. Burning and stretching pain in the perineum occurs as tissue stretches to allow for delivery of the fetus.