A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?

Slow paced breathing

Biofeedback

Self hypnosis

Acupuncture

Answer and Explanation

The Correct Answer is A

The correct answer is A. Slow-paced breathing

A. Slow-paced breathing is a nonpharmacological comfort measure that involves taking slow, deep breaths to promote relaxation and reduce anxiety. It can be an effective technique for managing pain during contractions.

B. Biofeedback involves the use of electronic monitoring to provide feedback about physiological processes, and it is not typically used as a primary nonpharmacological comfort measure for labor pain.

C. Self-hypnosis is a relaxation technique that involves guided imagery and focused concentration to promote relaxation and reduce pain. However, it may require some previous knowledge or practice, and in the context of this scenario, slow-paced breathing may be a more immediate and accessible option.

D. Acupuncture involves the insertion of needles into specific points on the body to stimulate energy flow. While acupuncture can be effective for pain management, it may not be readily available in all labor settings, and slow-paced breathing is a more universally applicable option.

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Correct Answer is B

Explanation

The correct answer is B. Turn the client onto her side.

A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.

B. Turning the client onto her side is the correct first action.

Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.

C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.

D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.

A. "The nurse will carry your newborn to the nursery for procedures." B. "We will document the relationship of visitors in your medical record. C. "Your baby will stay in the nursery while you are asleep." D. "Stall members who take care of your baby will be wearing a photo identification badge."

Correct Answer is D

Explanation

Choice A Reason:
"The nurse will carry your newborn to the nursery for procedures. "This statement is inappropriate. In current practice, there is an emphasis on family-centered care, and parents are often encouraged to be involved in the care of their newborns, including accompanying them for procedures whenever possible.

Choice B Reason:
"We will document the relationship of visitors in your medical record." This statement is inappropriate. While it is important to monitor and document visitors, the primary focus here is on healthcare staff and their identification.

Choice C Reason:
"Your baby will stay in the nursery while you are asleep." This statement is inappropriate. Promoting rooming-in and encouraging parental involvement in newborn care is a common practice to support bonding and breastfeeding, so this statement may not align with current best practices.

Choice D Reason:
"Staff members who take care of your baby will be wearing a photo identification badge." This statement reassures the client that the healthcare providers involved in the care of the newborn will have proper identification, enhancing security and ensuring that authorized personnel are handling the infant.

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A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?

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