Chapter 15: Pain Management During Childbirth My Nursing Test Banks

Chapter 15: Pain Management During Childbirth

MULTIPLE CHOICE

1. Childbirth preparation can be considered successful if the outcome is described as which of the following?

a.

Labor was pain-free.

b.

The birth experiences of friends and families were ignored.

c.

Only nonpharmacologic methods for pain control were used.

d.

The client rehearsed labor and practiced skills to master pain.

ANS: D

Preparation allows the woman to rehearse for labor and to learn new skills to cope with the pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a pain-free labor. A woman should be prepared for pain and anesthesia-analgesia realistically. Friends and families can be an important source of support if they convey realistic information about labor pain. Women will not always achieve their desired level of pain control by using nonpharmacologic methods alone.

PTS: 1 DIF: Cognitive Level: Analysis REF: 281

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Psychosocial Integrity

2. A woman with a known heroin habit is admitted in early labor. Which drug is contraindicated with opiate-dependent patients?

a.

Nalbuphine (Nubain)

b.

Hydroxyzine (Vistaril)

c.

Promethazine (Phenergan)

d.

Diphenhydramine (Benadryl)

ANS: A

Nalbuphine may precipitate withdrawal if given to an opiate-dependent woman. Hydroxyzine is an antihistamine with antiemetic effects. Promethazine usually relieves nausea and vomiting. Diphenhydramine is commonly used to relieve pruritus from epidural narcotics.

PTS: 1 DIF: Cognitive Level: Understanding REF: 293

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

3. A client is admitted to the labor and birth room in active labor; contractions are 4 to 5 minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment. When is the best time to ask questions or do procedures?

a.

After the contraction is over

b.

When it is all right with the coach

c.

During increment of next contraction

d.

After administration of analgesic-anesthetic

ANS: A

Reduce intrusions as much as possible. Longer assessments may span several contractions. The coach is the support person. The woman needs to feel confident in her ability to go through labor and birth, and she should be encouraged to express her own needs and concerns. The increment is the beginning of the next contraction. It is best to stop with questions and procedures during each contraction. An analgesic or anesthetic may cause adverse reactions in the woman, preventing her from answering questions correctly.

PTS: 1 DIF: Cognitive Level: Understanding REF: 297

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

4. Childbirth pain is different from other types of pain in that it is:

a.

less intense.

b.

associated with a physiologic process.

c.

more responsive to pharmacologic management.

d.

designed to make one withdraw from the stimulus.

ANS: B

Childbirth pain is part of a normal process, whereas other types of pain usually signify an injury or illness. Childbirth pain is not less intense than other types of pain. Pain management during labor may affect the course and length of labor. The pain with childbirth is a normal process; it is not caused by the type of injury as when withdrawal from the stimulus occurs.

PTS: 1 DIF: Cognitive Level: Understanding REF: 278

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

5. Excessive anxiety during labor heightens the clients sensitivity to pain by increasing:

a.

muscle tension.

b.

the pain threshold.

c.

blood flow to the uterus.

d.

rest time between contractions.

ANS: A

Anxiety and fear increase muscle tension, diverting oxygenated blood to the womans brain and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception, and reduced ability to use coping skills. Anxiety will decrease the pain threshold. Anxiety can decrease blood flow to the uterus. Anxiety will decrease the amount of rest the mother gets between contractions.

PTS: 1 DIF: Cognitive Level: Understanding REF: 280

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

6. Which fetal position may cause the laboring client more back discomfort?

a.

Left occiput anterior

b.

Left occiput posterior

c.

Right occiput anterior

d.

Right occiput transverse

ANS: B

In the left occiput posterior position, each contraction pushes the fetal head against the mothers sacrum, which results in intense back discomfort. Back labor is seen mostly when the fetus is in the posterior position.

PTS: 1 DIF: Cognitive Level: Understanding REF: 280

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

7. A major advantage of nonpharmacologic pain management is that:

a.

a more rapid labor is likely.

b.

more complete pain relief is possible.

c.

the woman remains fully alert at all times.

d.

there are no side effects or risks to the fetus.

ANS: D

Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. Pain management may or may not alter the length of labor. At times, when pain is decreased, the mother relaxes and labor progresses at a quicker pace. The womans alertness is not altered by medication, but the increase in pain will decrease alertness.

PTS: 1 DIF: Cognitive Level: Understanding REF: 281

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

8. The best time to teach nonpharmacologic pain control methods to an unprepared laboring client is during which stage?

a.

Latent phase

b.

Active phase

c.

Second stage

d.

Transition phase

ANS: A

The latent phase of labor is the best time for intrapartum teaching because the woman is usually anxious enough to be attentive yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the birth. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time.

PTS: 1 DIF: Cognitive Level: Understanding REF: 282

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

9. The primary side effect of maternal narcotic analgesia in the newborn is:

a.

tachypnea.

b.

bradycardia.

c.

acrocyanosis.

d.

respiratory depression.

ANS: D

An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics.

PTS: 1 DIF: Cognitive Level: Understanding REF: 293

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

10. A client received 25 mg of meperidine (Demerol) intravenously 1 hour before birth. Which drug should the nurse have readily available?

a.

Naloxone (Narcan)

b.

Butorphanol (Stadol)

c.

Nalbuphine (Nubain)

d.

Promethazine (Phenergan)

ANS: A

Naloxone (Narcan) reverses narcotic-induced respiratory depression, which may occur with the administration of narcotic analgesia. Phenergan is normally given for nausea. Nubain and Stadol are analgesics given to women in labor.

PTS: 1 DIF: Cognitive Level: Application REF: 294

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

11. The nerve block used in labor that provides anesthesia to the lower vagina and perineum is a(n):

a.

local.

b.

epidural.

c.

pudendal.

d.

spinal block.

ANS: C

A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

PTS: 1 DIF: Cognitive Level: Understanding REF: 295

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

12. A nurse is teaching a childbirth education class. Which information about excessive pain in labor should the nurse include in the session?

a.

It usually results in a more rapid labor.

b.

It has no effect on the outcome of labor.

c.

It is considered to be a normal occurrence.

d.

It may result in decreased placental perfusion.

ANS: D

When experiencing excessive pain, the woman may react with a stress response that diverts blood flow from the uterus and the fetus. Excessive pain may prolong the labor because of increased anxiety in the woman. It may affect the outcome of the labor, depending on the cause and the effect on the woman. Pain is considered normal for labor. However, excessive pain may be an indication of other problems and must be assessed.

PTS: 1 DIF: Cognitive Level: Application REF: 279

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

13. Which client will most likely have increased anxiety and tension during labor?

a.

Gravida 2 who refused any medication

b.

Gravida 2 who delivered a stillborn baby last year

c.

Gravida 1 who did not attend prepared childbirth classes

d.

Gravida 3 who has two children younger than 3 years

ANS: B

If a previous pregnancy had a poor outcome, the client will probably be more anxious during labor and birth. The client without childbirth education classes is not prepared for labor and will have increased anxiety during labor. However, the client with a poor previous outcome is more likely to experience more anxiety. A gravida 2 has previous experience and can anticipate what to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect.

PTS: 1 DIF: Cognitive Level: Analysis REF: 280

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

14. Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm cervical dilation?

a.

Narcotics

b.

Spinal block

c.

Epidural anesthesia

d.

Breathing and relaxation techniques

ANS: D

Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. At 8 cm cervical dilation there probably not enough time remaining to administer spinal anesthesia or epidural anesthesia. A narcotic given at this time may reach its peak at about the time of birth and result in respiratory depression in the newborn.

PTS: 1 DIF: Cognitive Level: Application REF: 297

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

15. A laboring client who imagines her body opening to let the baby out is using a mental technique called:

a.

imagery.

b.

effleurage.

c.

distraction.

d.

dissociation.

ANS: A

Imagery is a technique of visualizing images that will assist the woman in coping with labor. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman involved in another activity. Dissociation helps the woman learn to relax all muscles except those that are working.

PTS: 1 DIF: Cognitive Level: Understanding REF: 283

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

16. When giving a narcotic to a laboring client, which statement explains why the nurse should inject the medication at the beginning of a contraction?

a.

The medication will be rapidly circulated.

b.

Less medication will be transferred to the fetus.

c.

The maternal vital signs will not be adversely affected.

d.

Full benefit of the medication is received during that contraction.

ANS: B

Injecting at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. It will not increase the circulation of the medication. It will not alter the vital signs any more than giving it at another time. The full benefit will be received by the woman, but it will decrease the amount reaching the fetus.

PTS: 1 DIF: Cognitive Level: Application REF: 293, 294

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

17. The method of anesthesia in labor that is considered the safest for the fetus is:

a.

epidural block.

b.

pudendal block.

c.

local infiltration.

d.

spinal (subarachnoid) block.

ANS: C

Local infiltration of the perineum rarely has any adverse effects on the mother or the fetus. With an epidural, pudendal, or spinal block the fetus can be affected by maternal side effects and maternal hypotension.

PTS: 1 DIF: Cognitive Level: Understanding REF: 295

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

18. To improve placental blood flow immediately after the injection of an epidural anesthetic, the nurse should:

a.

give the woman oxygen.

b.

turn the woman to the right side.

c.

decrease the intravenous infusion rate.

d.

place a wedge under the womans right hip.

ANS: D

Tilting the womans pelvis to the left side relieves compression of the vena cava and compensates for a lower blood pressure without interfering with dispersal of the epidural medication. Oxygen administration will not improve placental blood flow. The woman needs to maintain the supine position for proper dispersal of the medication. However, placing a wedge under the hip will relieve compression of the vena cava. The intravenous infusion rate needs to be increased to prevent hypotension.

PTS: 1 DIF: Cognitive Level: Application REF: 286

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

19. Which clinical effect can occur in the presence of increased maternal pain perception during labor?

a.

Increase in uterine contractions in response to catecholamine secretion

b.

Decrease in blood pressure in response to alpha receptors

c.

Decreased perfusion to the placenta in response to catecholamine secretion

d.

Increased uterine blood flow, causing increase in maternal blood pressure

ANS: C

Decreased perfusion to and from the placenta occurs as result of catecholamine secretion. A decrease in uterine contractions is seen in response to catecholamine secretion. Maternal blood pressure is increased in response to alpha receptors. Decreased uterine blood flow causes an increase in maternal blood pressure.

PTS: 1 DIF: Cognitive Level: Analysis REF: 279

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

20. Which of the following factors would affect pain perception or tolerance for the laboring client?

a.

Right occiput posterior fetal position during labor

b.

Bishop score of 10 prior to the induction of labor

c.

Gynecoid pelvis

d.

Absence of Fergusons reflex

ANS: A

A fetus in the posterior position during labor can cause increased back pain to the mother because it is spine against spine. A Bishop score of 10 indicates that conditions are favorable for induction; the cervix is soft, anterior, effaced, and dilated and the presenting part is engaged. A gynecoid pelvic structure is considered to be an adequate passage for vaginal birth. Fergusons reflex occurs when a contraction is stimulated as a result of vaginal stimulation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 280

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

21. A client in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the client. Which priority intervention should be done by the nurse to help evaluate clinical response to treatment?

a.

Obtain a pain scale response from the client based on a 0 to 10 scale.

b.

Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations.

c.

Document intake and output on the electronic health record (EHR).

d.

Increase the flow rate of prescribed parenteral fluid to maintain hydration.

ANS: B

Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring client but used for postoperative and/or chronic pain clients. Intake and output should be documented as part of the clinical record but is not the priority intervention based on this clients situation. Increasing the flow rate of parenteral fluids requires a physicians order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess.

PTS: 1 DIF: Cognitive Level: Analysis REF: 285

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

22. The process of labor places significant metabolic demands on the obstetric client. Which physiologic findings would be expected?

a.

Decreased maternal blood pressure as a result of stimulation of alpha receptors

b.

Uterine vasoconstriction as a result of stimulation of beta receptors

c.

Increased maternal demand for oxygen

d.

Increased blood flow to placenta because of catecholamine release

ANS: C

With regard to labor, one would expect to see an increase in maternal blood pressure because of stimulation of alpha receptors. Uterine vasoconstriction would occur in response to stimulation of alpha receptors. One would expect to see a decrease in blood flow to the placenta. The maternal metabolic rate is increased during labor, along with an increase in maternal demand for oxygen.

PTS: 1 DIF: Cognitive Level: Analysis REF: 279

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

23. A labor client, gravida 2, para 1, at term has received meperidine (Demerol) for pain control during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal vital signs have been stable and the EFM tracing has not shown any baseline changes. Which medication does the nurse anticipate would be required in the birth room for administration?

a.

Oxytocin (Pitocin)

b.

Naloxone (Narcan)

c.

Bromocriptine (Parlodel)

d.

Oxygen

ANS: B

Because birth is imminent, and considering that the client has had a recent dose of narcotics, the nurse anticipates that naloxone (Narcan) will be administered to the newborn to combat the effects of the opioid. Although Pitocin will be given following birth of the placenta, the newborn will be delivered prior to that and will receive priority intervention. Parlodel is not typically given in the labor and birth area any more. It was previously used to suppress lactation. At present, there is no need for the administration of oxygen because there is no evidence that the mother is showing any signs of respiratory depression.

PTS: 1 DIF: Cognitive Level: Analysis REF: 291

OBJ: Nursing Process Step: Planning

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

24. Which statement is true with regard to the type of pain associated with childbirth experience?

a.

Pain is constant throughout the labor experience.

b.

Labor pain during childbirth is considered to be an abnormal response.

c.

Pain associated with childbirth is self-limiting.

d.

Pain associated with childbirth does not allow for adequate preparation.

ANS: C

The pain associated with childbirth is self-limiting in that it typically stops once the child is delivered. Pain is intermittent during the labor experience. Labor pain is considered to be a normal response during childbirth. Pregnant woman can prepare for the expected pain of childbirth by taking prepared childbirth classes and using relaxation techniques during the course of labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 278

OBJ: Nursing Process Step: Planning

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

25. A pregnant woman is in the second stage of labor and is actively pushing. What type of pain would she be most likely to experience?

a.

Deep, poorly localized pain

b.

Visceral pain

c.

Slow, dull, aching pain

d.

Somatic pain

ANS: D

Somatic pain is quick, sharp, and precisely localized and is seen during the second stage of labor. Deep, poorly localized pain is associated with visceral pain, which predominates during the first stage of labor. Visceral pain is slow, deep, dull, aching, and poorly localized. Slow, dull, aching pain is characteristic of visceral pain.

PTS: 1 DIF: Cognitive Level: Analysis REF: 279

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

26. A client in labor reports a feeling of burning pain during the second stage of labor. This type of pain is associated with:

a.

visceral pain.

b.

tissue ischemia.

c.

somatic pain.

d.

cervical dilation.

ANS: C

This is an example of somatic pain experienced as a result of distention of the vagina and perineum during the second stage of labor. Visceral pain occurs in response to pressure on pelvic structures. Pain associated with ischemic tissue is a result of decreased blow flow to the uterus. The pain of cervical dilation is a major pain source during labor but, during the second stage of labor, the client is already fully dilated so this would not be a factor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 279

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

27. Which of the following clients could be a candidate for a vaginal birth after cesarean section (VBAC)?

a.

A 32-year-old gravida 2, para 1, who had a primary cesarean section for fetal distress

b.

A 23-year-old gravida 3, para 2, who had two cesarean sections with classic incisions

c.

An 18-year-old gravida 3, para 2, who had cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively

d.

A 25-year-old gravida 1, para 0, who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth

ANS: A

VBAC can be done if the need for the primary cesarean section was based on factors other than cephalopelvic disproportion (CPD) and macrosomia. A client who has had a prior classic incision into the uterus is not a candidate for this type of procedure. Based on the presented history of a cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively, this client is at risk for uterine rupture and for delivering another macrosomic infant because she has already had two cesarean sections for the same indications. A client who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth is not a candidate for a VBAC because she does not meet the clinical criteria.

PTS: 1 DIF: Cognitive Level: Analysis REF: 281

OBJ: Nursing Process Step: Planning

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

28. A client presents to the labor and birth area for emergent birth. Vaginal exam reveals that the client is fully dilated, vertex, +2 station, with ruptured membranes. The client is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this client assessment?

a.

Use contact anesthesia for an epidural and prepare the client per protocol.

b.

Tell the client that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop.

c.

Assist the client with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth.

d.

Call the physician for admitting orders.

ANS: C

By assisting the client with nonpharmacologic methods of pain distraction, the nurse is focusing on the clients needs while still preparing for vaginal birth. The client presents in an emergent situation with birth being imminent. Thus, there is not enough time to administer an epidural. Telling the client that she will not need any pain medication because the birth will be over soon does not address the clients concerns of apprehension and therefore is not therapeutic. Because this is an emergency birth situation, the nurse should be attending to the client. If needed, another nurse and/or supervisor can contact the physician.

PTS: 1 DIF: Cognitive Level: Analysis REF: 287

OBJ: Nursing Process Step: Planning

MSC: Client Needs: Safe and Effective Care Environment

29. A labor client has brought in with her a picture of her two children and asks the nurse to place it on the wall so that she can look at it during labor contractions. This is an example of:

a.

focal point.

b.

distraction.

c.

effleurage.

d.

relaxation.

ANS: A

The use of a focal point (image and/or point reference in the labor room) is an example of nonpharmacologic pain control during labor. The image of the clients children is not serving as a method of distraction. Effleurage is the use of massage techniques to minimize pain perception. The image of the clients children is not serving as a method of relaxation.

PTS: 1 DIF: Cognitive Level: Application REF: 283

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

30. A pregnant woman in labor is quite anxious and has been breathing rapidly during contractions. She now complains of a tingling sensation in her fingers. What is the priority nursing intervention?

a.

Perform a vaginal exam to denote progress.

b.

Reposition the client to a side lying position.

c.

Instruct the client to breathe into her cupped hands.

d.

Notify the physician about current findings.

ANS: C

This client is exhibiting signs of hyperventilation associated with a rapid breathing pattern, which can occur during the labor process. The nurse should instruct the client to breathe into her cupped hands to retain carbon dioxide that is being lost from the hyperventilation process. A vaginal exam is not indicated because there is no evidence of fetal distress and/or change in labor progress. Repositioning the client may be an option but is not the priority intervention at this time. Notifying the physician is not appropriate at this time because the RN should attend to actions that are readily available to her based on her scope of practice and standard of care. The physician may have to be notified once the intervention has been performed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 285

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

31. Your laboring client has asked that you help her to use a cutaneous stimulation strategy for pain management, you would then:

a.

assist her into the shower.

b.

apply a heat pack to lower back.

c.

help her to create a relaxing mental scene.

d.

encourage cleansing breaths and slow-paced breathing.

ANS: B

Cutaneous stimulation includes self-massage, massage by others, counterpressure, touch, thermal stimulation, and acupressure. A shower, tub, or whirlpool are forms of hydrotherapy; creating a relaxed mental scene is mental stimulation. The use of cleansing breaths and patterned breathing is part of breathing techniques for labor.

PTS: 1 DIF: Cognitive Level: Application REF: 282

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

32. To relieve a mild postdural puncture headache, the nurse should encourage the intake of:

a.

milk.

b.

orange juice.

c.

tea or coffee.

d.

beef or chicken bouillon.

ANS: C

Caffeine is an oral therapy that is beneficial in relieving postdural puncture headache. Milk, juices, and bouillon will add oral hydration but lack the added benefit of the caffeine.

PTS: 1 DIF: Cognitive Level: Application REF: 292

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

33. The priority intervention for a client with epidural anesthesia whose blood pressure is 80/50 mm Hg is:

a.

reposition to supine position.

b.

administer ephedrine, 5 mg IV push.

c.

maintain IV infusion rate at 150 mL/hr.

d.

Notify anesthesia about maternal hypotension.

ANS: B

A significant blood pressure decrease is a drop to 100 mm Hg or lower systolic. If hypotension is significant, ephedrine is ordered to increase the blood pressure to normal values. The supine position will further decrease maternal blood pressure by compressing the major vessels. Maintaining the IV infusion rate will not return blood pressure to normal values as quickly as needed; immediate action needs to be taken, and notifying anesthesia would be time-consuming.

PTS: 1 DIF: Cognitive Level: Application REF: 301

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

34. Which client will be most receptive to teaching about nonpharmacologic pain control methods?

a.

Gravida 1, para 0, in transition

b.

Gravida 2, para 1, admitted at 8 cm

c.

Gravida 1, para 0, dilated 2 cm, 80% effaced

d.

Gravida 3, para 2, complaining of intense perineal pressure

ANS: C

The latent phase of labor is the best time for intrapartum teaching; the latent phase of labor is the first centimeter of cervical dilation. Clients in the transition phase (8 to 10 cm) are experiencing intense pain and are not receptive to teaching. A multigravida complaining of intense perineal pressure indicates a client whose birth is imminent.

PTS: 1 DIF: Cognitive Level: Analysis REF: 282

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

35. The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurses priority action for this patient?

a.

Ask the patients labor coach if this is a usual expression of pain for her.

b.

Refer to the patients chart to determine any orders for pain medication.

c.

Tell the patient that she is disturbing the other laboring patients on the unit.

d.

Encourage the patient to try to suppress her noisiness during contractions.

ANS: A

Women should be encouraged to express themselves in any way they find comforting, and the diversity of their expressions must be respected. Loud and vigorous expression may be a womans personal pain coping mechanism, whereas a quiet woman may need medication relief but feels the need to remain stoic. Accepting a womans individual response to labor and pain promotes a therapeutic relationship. Restraint is difficult because noisy women are challenging to work with and may disturb others.

PTS: 1 DIF: Cognitive Level: Application REF: 280

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

36. A multiparas labor plan includes the use of jet hydrotherapy during the active phase of labor. What is the priority patient assessment prior to assisting the patient with this request?

a.

Maternal pulse

b.

Maternal temperature

c.

Maternal blood pressure

d.

Maternal blood glucose level

ANS: B

A shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. Several studies have shown benefits of water therapy during labor, including immersion in a tub or whirlpool (jet hydrotherapy, or Jacuzzi). The major concern about immersion therapy has been newborn and postpartum maternal infections caused by microorganisms in the water. Infections can be caused by the womans own ascending vaginal bacteria or by preexisting organisms in an improperly cleaned tub. However, several studies have not found a significant association between newborn or postpartum maternal infections and the use of immersion hydrotherapy with proper cleaning.

PTS: 1 DIF: Cognitive Level: Application REF: 283

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

37. A patient in active labor requests an epidural for pain management. What is the nurses priority action for this patient?

a.

Assess the fetal heart rate pattern over the next 30 minutes.

b.

Take the patients blood pressure every 5 minutes for 15 minutes.

c.

Determine the patients contraction pattern for the next 30 minutes.

d.

Initiate an IV infusion of lactated Ringers solution at 2000 mL/hr over 30 minutes.

ANS: D

Rapid infusion of a nondextrose IV solution, often warmed, such as lactated Ringers or normal saline, before initiation of the block fills the vascular system to offset vasodilation. Preload IV quantities are at least 500 to 1000 mL infused rapidly. Vasodilation with corresponding hypotension can reduce placental perfusion and is most likely to occur within the first 15 minutes after the initiation of the epidural. Determining the fetal heart rate every 30 minutes is the standard of care. The patient is in active labor, which indicates a contraction pattern resulting in cervical dilation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 289

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

38. Meperidine (Demerol), 50 mg IV, has been ordered for a laboring patient. The patient is contracting every 3 minutes, with a duration of 45 to 60 seconds. What is the nurses best plan for administering the IV medication?

a.

Inject the medication between two contractions.

b.

Inject the medication during and after a single contraction.

c.

Inject the medication at the start of the next two contractions.

d.

Inject the medication throughout the duration of a single contraction.

ANS: C

The suggested administration of IV Demerol is 25 mg/min and therefore will need to be administered over the course of two contractions. Opioid analgesics are given in small frequent doses by the IV route during labor to provide a rapid onset of analgesia and predictable duration of action. The woman will benefit from rapid pain control, with less likelihood of neonatal respiratory depression. Starting the injection at the beginning of the contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. When placental blood flow resumes, more of the drug is in maternal tissues.

PTS: 1 DIF: Cognitive Level: Analysis REF: 293

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

39. You are preparing a client for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.)

a.

Administer a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement.

b.

Have ephedrine available at bedside during catheter placement.

c.

Monitor blood pressure of client frequently during catheter insertion and for the first 15 minutes of epidural administration.

d.

Insert a Foley catheter prior to epidural catheter placement.

e.

Monitor the client for hypertension in response to epidural insertion.

ANS: B, C

A bolus of nondextrose fluid is recommended prior to epidural administration to prevent maternal hypotension. Ephedrine should be available at the bedside in case maternal hypotension is exhibited. Blood pressure should be monitored frequently during insertion and for the first 15 minutes of therapy. It is not necessary to insert a Foley catheter prior to epidural catheter placement. Hypertension is not a common clinical response to this treatment but hypotension is.

PTS: 1 DIF: Cognitive Level: Application REF: 300

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

40. While developing an intrapartum care plan for the client in early labor, it is important that the nurse recognize that psychosocial factors may influence a womans experience of pain. These include which of the following? (Select all that apply.)

a.

Culture

b.

Anxiety and fear

c.

Support systems

d.

Preparation for childbirth

e.

Previous experiences with pain

ANS: A, B, C, D, E

Culture: A womans sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression).

Anxiety and fear: Extreme anxiety and fear magnify sensitivity to pain and impair a womans ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts.

Support systems: An anxious partner is less able to provide help and support to a woman during labor. A womans family and friends can be an important source of support if they convey realistic and positive information about labor and birth.

Preparation for childbirth: This does not ensure a pain-free labor. Preparation does reduce anxiety and fear. It also allows a woman to rehearse for labor.

Previous experiences with pain: Fear and withdrawal are natural responses to pain during labor.

Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience.

PTS: 1 DIF: Cognitive Level: Application REF: 280, 281

OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity

41. The nurse detects hypotension in a laboring client after an epidural. Which actions should the nurse plan to implement? (Select all that apply.)

a.

Encourage the client to drink fluids.

b.

Place the client in a Trendelenburg position.

c.

Administer a normal saline bolus as prescribed.

d.

Administer oxygen at 8 to 10 L/min per face mask.

e.

Administer IV ephedrine in 5- to 10-mg increments as prescribed.

ANS: C, D, E

If hypotension occurs after an epidural has been placed, techniques such as a rapid nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments can be prescribed to promote vasoconstriction to raise the blood pressure. The client in active labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat, with the feet elevated. This would not be a position to use for a pregnant client.

PTS: 1 DIF: Cognitive Level: Application REF: 289

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

42. The nurse is preparing a client for a cesarean section scheduled to be done under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents?(Select all that apply.)

a.

Citric acid (Bicitra)

b.

Ranitidine (Zantac)

c.

Hydroxyzine (Vistaril)

d.

Glycopyrrolate (Robinul)

e.

Promethazine (Phenergan)

ANS: A, B, D

To prevent aspiration of gastric contents during general anesthesia administration of medications to raise the gastric pH and make secretions less acidic, such as citric acid (Bicitra) and ranitidine (Zantac) may be prescribed. In addition, medications to reduce secretions, such as glycopyrrolate (Robinul) may be prescribed. Hydroxyzine (Vistaril) and promethazine (Phenergan) are used to prevent and relieve nausea often associated with opioids.

PTS: 1 DIF: Cognitive Level: Analysis REF: 296

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

MATCHING

Match each term with the correct definition.

a.

Pressure applied to specific pressure points using hands, rollers, balls, or other equipment

b.

Contraction and then release of specific muscle groups until all muscles are relaxed

c.

Concentrating on something outside the body

43. Focal point

44. Acupressure

45. Progressive relaxation

43. ANS: C PTS: 1 DIF: Cognitive Level: Understanding

REF: 291 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion and Maintenance

NOT: Progressive relaxation is contraction and then release of specific muscle groups until all muscles are relaxed. Acupressure is pressure applied to specific pressure points using hands, rollers, balls, or other equipment. A focal point is concentrating on an object outside the body and away from the pain of contractions.

44. ANS: A PTS: 1 DIF: Cognitive Level: Understanding

REF: 291 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion and Maintenance

NOT: Progressive relaxation is contraction and then release of specific muscle groups until all muscles are relaxed. Acupressure is pressure applied to specific pressure points using hands, rollers, balls, or other equipment. A focal point is concentrating on an object outside the body and away from the pain of contractions.

45. ANS: B PTS: 1 DIF: Cognitive Level: Understanding

REF: 283 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion and Maintenance

NOT: Progressive relaxation is contraction and then release of specific muscle groups until all muscles are relaxed. Acupressure is pressure applied to specific pressure points using hands, rollers, balls, or other equipment. A focal point is concentrating on an object outside the body and away from the pain of contractions.

SHORT ANSWER

46. The health care providers prescription reads diphenhydramine (Benadryl), 25 mg IV stat. The medication vial reads diphenhydramine (Benadryl), 50 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Record your answer to one decimal point.

_____ mL

ANS:

0.5 mL

Desired/available volume = milliliters per dose

25 mg/50 mg 1 mL = 0.5 mL/per dose

PTS: 1 DIF: Cognitive Level: Application REF: 283

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

47. The nurse is administering fentanyl (Sublimaze) to a client in labor. The health care providers prescription reads fentanyl (Sublimaze), 100 mcg IV stat. The medication vial reads fentanyl (Sublimaze), 50 mcg/mL. The nurse should prepare how many milliliters to administer the correct dose? Record your answer as a whole number.

_____ mL

ANS:

2 mL

Desired/available volume = milliliters per dose

100 mcg/50 mcg 1 mL = 2 mL/dose

PTS: 1 DIF: Cognitive Level: Application REF: 282

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

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