A nurse in a prenatal clinic is reinforcing teaching with a group of women about the use of acupressure to relieve discomfort during labor.
Which of the following instructions should the nurse include in the teaching?
Use light strokes on the abdomen with a rhythmic breathing pattern.
Immerse yourself in a tub of warm water.
Place tennis balls on the sacral area and lean against them.
Recognize specific signals, respond, and relax.
The Correct Answer is D
Choice A rationale
Light strokes on the abdomen with rhythmic breathing, known as effleurage, are a distraction technique during labor. This method stimulates large-diameter nerve fibers, competing with pain signals transmitted by smaller-diameter fibers, thus reducing the perception of pain. While helpful, it is not directly related to acupressure, which involves targeted pressure points.
Choice B rationale
Immersing oneself in warm water, or hydrotherapy, promotes muscle relaxation and reduces pain perception through buoyancy and heat transfer. The warmth increases blood flow and relaxes uterine muscles, providing comfort. This technique primarily acts on thermoreceptors and mechanoreceptors, facilitating systemic relaxation, distinct from the focused pressure of acupressure.
Choice C rationale
Placing tennis balls on the sacral area and leaning against them applies counterpressure, a technique effective for back labor. This external pressure can help alleviate pain by applying direct compression to the sacral nerves, which may be compressed by the fetal head. This method is a form of deep tissue manipulation, differing from the specific point stimulation of acupressure.
Choice D rationale
Acupressure involves applying pressure to specific anatomical points to alleviate pain and discomfort. Recognizing signals (e.g., contractions), responding (applying pressure), and relaxing (allowing the body's natural pain modulation) are key principles. This targets endogenous opioid release and influences neural pathways, promoting pain relief and often a sense of calm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
? Rationale for Correct Answers
Diabetic diet is appropriate because the client meets diagnostic criteria for gestational diabetes mellitus (GDM). The 3-hour oral glucose tolerance test (OGTT) shows two or more elevated values:
- 1-hour: 220 mg/dL (normal <180 mg/dL)
- 2-hour: 165 mg/dL (normal <140 mg/dL)
- 3-hour: 142 mg/dL (normal 70–115 mg/dL)
According to the American Diabetes Association and ACOG, GDM is diagnosed when at least two values exceed thresholds. GDM increases risks for macrosomia, preeclampsia, and neonatal hypoglycemia, and requires dietary management as first-line therapy.
30 cal/kg/day is the recommended caloric intake for overweight or obese pregnant individuals with GDM. Caloric needs are based on pre-pregnancy weight:
- Normal BMI: 30–35 kcal/kg/day
- Overweight (BMI 25–29.9): 25 kcal/kg/day
- Obese (BMI ≥30): 30 kcal/kg/day is often used to balance fetal growth and glycemic control.
❌ Rationale for Incorrect Response 1 Options
Low-sodium diet is used for hypertension or preeclampsia, but this client has no signs of preeclampsia (e.g., proteinuria, headache, visual changes, epigastric pain).
High-protein diet is not a standard intervention for GDM and may worsen insulin resistance if not balanced.
Gluten-free diet is indicated for celiac disease, which is not present here.
❌ Rationale for Incorrect Response 2 Options
15–25 cal/kg/day are too low for pregnancy and may risk fetal growth restriction, especially in obese clients.
20 cal/kg/day is used in severe obesity or when caloric restriction is medically necessary, but not standard for GDM.
25 cal/kg/day is more appropriate for overweight (not obese) clients.
? Take-Home Points
- GDM is diagnosed with ≥2 abnormal values on a 3-hour OGTT.
- Dietary therapy is first-line management for GDM, focusing on controlled carbohydrate intake.
- Obese pregnant clients with GDM should receive ~30 kcal/kg/day based on pre-pregnancy weight.
- GDM increases risks for maternal and fetal complications and requires close monitoring.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
? Rationale for Correct Answers
2 oz of formula is appropriate as the first intervention because the newborn is experiencing symptomatic hypoglycemia (glucose 35 mg/dL) and had difficulty latching during breastfeeding. Formula provides a rapid source of glucose to correct hypoglycemia when breastfeeding is insufficient or ineffective. The goal is to raise blood glucose above 45 mg/dL to prevent neurologic injury.
Skin-to-skin contact supports thermoregulation, glucose stabilization, and neurobehavioral organization. It enhances bonding and promotes successful breastfeeding, which is essential for ongoing glucose maintenance. After feeding, skin-to-skin helps maintain euglycemia and calm the newborn.
❌ Rationale for Incorrect Response 1 Options
Morphine per protocol is used for neonatal abstinence syndrome (NAS), not hypoglycemia. There is no history of maternal opioid use or signs of withdrawal (e.g., hypertonia, sneezing, diarrhea).
Oxygen via nasal cannula is indicated for respiratory distress or hypoxia. This newborn has normal respiratory rate (45/min) and unlabored breathing, so oxygen is unnecessary.
Swaddling with legs flexed is a comfort measure, not a treatment for hypoglycemia. While it may reduce energy expenditure, it does not address the underlying glucose deficit.
❌ Rationale for Incorrect Response 2 Options
Dextrose 50% is hypertonic and contraindicated in neonates due to risk of vein damage and rebound hypoglycemia. Oral feeding is preferred for mild hypoglycemia; IV dextrose (usually D10W) is reserved for severe or refractory cases.
Naloxone is used to reverse opioid-induced respiratory depression. There is no evidence of opioid exposure or respiratory compromise in this newborn.
Antibiotics are used for suspected sepsis. This newborn is afebrile, alert, and without signs of infection.
? Take-Home Points
- Symptomatic neonatal hypoglycemia should be treated promptly with oral feeding (breast milk or formula).
- Formula is appropriate when breastfeeding is ineffective or delayed.
- Skin-to-skin contact supports glucose regulation and promotes breastfeeding success.
- IV dextrose is reserved for severe or persistent hypoglycemia unresponsive to feeding.
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