Chapter 17 Flashcards
- An 18-year-old pregnant woman, gravida 1, para 0, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The client states, “My contractions are so strong, I don’t know what to do.” Before making a plan of care, what should the nurse’s first action be?
a.
Assess for fetal well-being.
b.
Encourage the woman to lie on her side.
c.
Disturb the woman as little as possible.
d.
Recognize that pain is personalized for each individual.
ANS: D
Each woman’s pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. This scenario includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support.
- A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively; she states that she did not attend childbirth classes. What is the optimal intervention for the nurse to provide at this time?
a.
Notify the woman’s health care provider.
b.
Administer the prescribed narcotic analgesic.
c.
Assure her that her labor will be over soon.
d.
Assist her with simple breathing and relaxation instructions.
ANS: D
By reducing tension and stress, both focusing and relaxation techniques will allow the woman in labor to rest and conserve energy for the task of giving birth. For those who have had no preparation, instruction in simple breathing and relaxation can be given in early labor and is often successful. The nurse can independently perform many functions in labor and birth, such as teaching and support. Pain medication may be an option for this client. However, the initial response of the nurse should include teaching the client about her options. The length of labor varies among individuals, but the first stage of labor is the longest. At 3 cm of dilation with contractions every 5 minutes, this woman has a significant amount of labor yet to experience.
- Nursing care measures are commonly offered to women in labor. Which nursing measure reflects the application of the gate-control theory?
a.
Massage the woman’s back.
b.
Change the woman’s position.
c.
Give the prescribed medication.
d.
Encourage the woman to rest between contractions.
ANS: A
According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques, such as massage or stroking, music, focal points, and imagery, reduce or completely block the capacity of the nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the woman’s position, administering pain medication, and resting between contractions do not reduce or block the capacity of the nerve pathways to transmit pain using the gate-control theory.
- Breathing patterns are taught to laboring women. Which breathing pattern should the nurse support for the woman and her coach during the latent phase of the first stage of labor if the couple has attended childbirth preparation classes?
a.
Slow-paced breathing
b.
Deep abdominal breathing
c.
Modified-paced breathing
d.
Patterned-paced breathing
ANS: A
Slow-paced breathing is approximately one half the woman’s normal breathing rate and is used during the early stages of labor when a woman can no longer walk or talk through her contractions. No such pattern called deep abdominal breathing exists in childbirth preparation. Modified-paced breathing is shallow breathing that is twice the woman’s normal breathing rate. It is used when labor progresses and the woman can no longer maintain relaxation through paced breathing. Patterned-pace breathing is a fast, 4:1 breathe, breathe, breathe, blow pattern that is used during the transitional phase of labor just before pushing and delivery.
- A laboring woman has received meperidine (Demerol) intravenously (IV), 90 minutes before giving birth. Which medication should be available to reduce the postnatal effects of meperidine on the neonate?
a.
Fentanyl (Sublimaze)
b.
Promethazine (Phenergan)
c.
Naloxone (Narcan)
d.
Nalbuphine (Nubain)
ANS: C
An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists, such as naloxone (Narcan), can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl (Sublimaze), promethazine (Phenergan), and nalbuphine (Nubain) do not act as opioid antagonists to reduce the postnatal effects of meperidine on the neonate.
- What should the laboring client who receives an opioid antagonist be told to expect?
a.
Her pain will decrease.
b.
Her pain will return.
c.
She will feel less anxious.
d.
She will no longer feel the urge to push.
ANS: B
Opioid antagonists such as naloxone (Narcan) promptly reverse the CNS-depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if the labor is more rapid than expected and the birth is anticipated when the opioid is at its peak effect. The woman should be told that the pain that was relieved by the opioid analgesic will return with the administration of the opioid antagonist. Her pain level will increase rather than decrease. Opioid antagonists have no effect on anxiety levels. They are primarily administered to reverse the excessive CNS depression in the mother, newborn, or both. An opioid antagonist (e.g., naloxone) has no effect on the mother’s urge or ability to push. The practice of giving lower doses of IV opioids has reduced the incidence and severity of opioid-induced CNS depression; therefore, opioid antagonists are used less frequently.
- A client is in early labor, and her nurse is discussing the pain relief options she is considering. The client states that she wants an epidural “no matter what!” What is the nurse’s best response?
a.
“I’ll make sure you get your epidural.”
b.
“You may only have an epidural if your physician allows it.”
c.
“You may only have an epidural if you are going to deliver vaginally.”
d.
“The type of analgesia or anesthesia used is determined, in part, by the stage of your labor and the method of birth.”
ANS: D
To avoid suppressing the progress of labor, pharmacologic measures for pain relief are generally not implemented until labor has advanced to the active phase of the first stage and the cervix is dilated approximately 4 to 5 cm. A plan of care is developed for each woman that addresses her particular clinical and nursing problems. The nurse collaborates with the primary health care provider and the laboring woman in selecting features of care relevant to the woman and her family. The decision whether to use an epidural to relieve labor pain is multifactorial. The nurse should not make a blanket statement guaranteeing the client one pharmacologic option over another until a complete history and physical examination has been obtained. A physician’s order is required for pharmacologic options for pain management. However, expressing this requirement is not the nurse’s best response. An epidural is an effective pharmacologic pain management option for many laboring women. It can also be used for anesthesia control if the woman undergoes an operative delivery.
- What is the role of the nurse as it applies to informed consent?
a.
Inform the client about the procedure, and ask her to sign the consent form.
b.
Act as a client advocate, and help clarify the procedure and the options.
c.
Call the physician to see the client.
d.
Witness the signing of the consent form.
ANS: B
Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the woman’s advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician must be present to explain the procedure to the client. However, the nurse’s responsibilities go further than simply asking the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the state’s guidelines, the woman’s husband or another hospital health care employee may sign as a witness.
- A first-time mother is concerned about the type of medications she will receive during labor. The client is in a fair amount of pain and is nauseated. In addition, she appears to be very anxious. The nurse explains that opioid analgesics are often used along with sedatives. How should the nurse phrase the rationale for this medication combination?
a.
“The two medications, together, reduce complications.”
b.
“Sedatives enhance the effect of the pain medication.”
c.
“The two medications work better together, enabling you to sleep until you have the baby.”
d.
“This is what your physician has ordered for you.”
ANS: B
Sedatives may be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractic drugs reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause two drugs to work together more effectively, but it does not ensure zero maternal or fetal complications. Sedation may be a related effect of some ataractic drugs; however, sedation is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. Although the physician may have ordered the medication, “This is what your physician has ordered for you” is not an acceptable comment for the nurse to make.
- The nurse should be cognizant of which physiologic effect of pain?
a.
Predominant pain of the first stage of labor is visceral pain that is located in the lower portion of the abdomen.
b.
Referred pain is the extreme discomfort experienced between contractions.
c.
Somatic pain of the second stage of labor is more generalized and related to fatigue.
d.
Pain during the third stage is a somewhat milder version of the pain experienced during the second stage.
ANS: A
Predominant pain comes from cervical changes, the distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage.
- Which statement correctly describes the effects of various pain factors?
a.
Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth.
b.
Upright positions in labor increase the pain factor because they cause greater fatigue.
c.
Women who move around trying different positions experience more pain.
d.
Levels of pain-mitigating beta-endorphins are higher during a spontaneous, natural childbirth.
ANS: D
Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension.
- Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help their clients. Which clients may initially appear very stoic but then become quite vocal as labor progresses until late in labor, when they become more vocal and request pain relief?
a.
Chinese
b.
Arab or Middle Eastern
c.
Hispanic
d.
African-American
ANS: C
Hispanic women may be stoic early in labor but more vocal and ready for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start; they may prefer pain medications. African-American women may openly express pain; the use of medications for pain is more likely to vary with the individual.
- Anxiety is commonly associated with pain during labor. Which statement regarding anxiety is correct?
a.
Even mild anxiety must be treated.
b.
Severe anxiety increases tension, increases pain, and then, in turn, increases fear and anxiety, and so on.
c.
Anxiety may increase the perception of pain, but it does not affect the mechanism of labor.
d.
Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.
ANS: B
Anxiety and pain reinforce each other in a negative cycle that will slow the progress of labor. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can sufficiently build to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.
- Which statement is not an expected outcome for the client who attends a reputable childbirth preparation program?
a.
Childbirth preparation programs increase the woman’s sense of control.
b.
Childbirth preparation programs prepare a support person to help during labor.
c.
Childbirth preparation programs guarantee a pain-free childbirth.
d.
Childbirth preparation programs teach distraction techniques.
ANS: C
All methods try to increase a woman’s sense of control, prepare a support person, and train the woman in physical conditioning, which includes breathing techniques. These programs cannot, and reputable ones do not, promise a pain-free childbirth. Increasing a woman’s sense of control is the goal of all childbirth preparation methods. Preparing a support person to help in labor is a vitally important component of any childbirth education program. The coach may learn how to touch a woman’s body to detect tense and contracted muscles. The woman then learns how to relax in response to the gentle stroking by the coach. Distraction techniques are a form of care that are effective to some degree in relieving labor pain and are taught in many childbirth programs. These distractions include imagery, feedback relaxation, and attention-focusing behaviors.
- Maternity nurses often have to answer questions about the many, sometimes unusual, ways people have tried to make the birthing experience more comfortable. Which information regarding nonpharmacologic pain relief isaccurate?
a.
Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine.
b.
Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time.
c.
Effleurage is permissible, but counterpressure is almost always counterproductive.
d.
Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.
ANS: D
Transcutaneous electrical nerve stimulation (TENS) may help and is most useful for lower back pain that occurs during the first stage of labor. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks might be more effective than one long bath. Counterpressure can help the woman cope with lower back pain.