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 D
Explanation
Choice A rationale
Multiple gestation, such as twins or triplets, typically results in elevated maternal serum alpha-fetoprotein (MSAFP) levels because there are multiple fetuses producing AFP. AFP is a protein produced by the fetal liver and yolk sac.
Choice B rationale
Neural tube defects, such as spina bifida or anencephaly, are associated with *elevated* levels of MSAFP due to the open defect allowing leakage of AFP into the amniotic fluid and then into the maternal circulation.
Choice C rationale
Intrauterine growth restriction (IUGR) can sometimes be associated with either normal or slightly elevated MSAFP levels, depending on the underlying cause, but it is not typically linked to *low* levels.
Choice D rationale
Low levels of maternal serum alpha-fetoprotein are associated with an increased risk of Down syndrome (Trisomy 21). This is thought to be due to altered placental function or fetal production of AFP in these pregnancies.
Correct Answer is B
Explanation
Choice A rationale:
At approximately 20 weeks of gestation, the fundus is typically located at the level of the umbilicus. By 32 weeks, the uterus has grown significantly beyond this point. Therefore, a fundal height at the umbilicus would be inconsistent with 32 weeks gestation and may suggest intrauterine growth restriction or incorrect dating if observed.
Choice B rationale:
At 32 weeks of gestation, the fundus is expected to be located about halfway between the umbilicus and the xiphoid process. Fundal height in centimeters generally correlates with gestational age between 20 and 36 weeks. Thus, a measurement of approximately 32 cm from the symphysis pubis to the top of the fundus is expected, placing it midway between these anatomical landmarks.
Choice C rationale:
The fundus typically reaches the xiphoid process around 36 to 40 weeks of gestation. At 32 weeks, it has not yet ascended to this level. A fundal height at the xiphoid process at 32 weeks may suggest polyhydramnios, macrosomia, or multiple gestation, and would require further evaluation.
Choice D rationale:
At 16 weeks of gestation, the fundus is generally located halfway between the symphysis pubis and the umbilicus. By 32 weeks, the uterus has expanded well beyond this point. A fundal height at this level would be abnormally low for 32 weeks and could indicate fetal growth restriction or oligohydramnios.
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