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
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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Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence
Choice B Reason:
Temperature:Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes.The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.
Choice C Reason:
Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.
Choice D Reason:
Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.
Correct Answer is C
Explanation
The correct answer is C. Place the client in a lateral position.
A. Elevating the client's legs is not the priority in this situation. Placing the client in a lateral position is more appropriate to improve blood flow and prevent supine hypotension.
B. Notifying the provider is an important action but not the immediate priority. Addressing the client's position and blood pressure is crucial before contacting the provider.
C. Placing the client in a lateral position is the priority nursing action.
The low blood pressure may be due to aortocaval compression (supine hypotension) caused by the weight of the uterus on the vena cava. Turning the client onto her side alleviates this compression and helps improve blood flow.
D. Monitoring vital signs every 5 minutes is important, but the immediate action should be to address the client's position and blood pressure. Continuous monitoring and further interventions can follow.
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