A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?

Apply sacral counterpressure.

Perform transcutaneous electrical nerve stimulation (TENS)

Initiate slow-paced breathing.

Assist with biofeedback

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Applying sacral counterpressure is appropriate. In the right occiput posterior position, the fetal head is positioned towards the mother's back, leading to increased pressure on the sacral are

A. Applying sacral counterpressure can help alleviate back pain during contractions.

Choice B Reason:

Performing transcutaneous electrical nerve stimulation (TENS) is inappropriate. While TENS can be used for pain relief in labor, applying sacral counterpressure is a more specific intervention for back pain related to fetal positioning.

Choice C Reason:

Initiating slow-paced breathing is inappropriate. While slow-paced breathing is a coping mechanism during contractions, it may not specifically address the back pain associated with the fetus in the right occiput posterior position.

Choice D Reason:

Assisting with biofeedback is inappropriate. Biofeedback is not a standard intervention for managing back pain during labor, especially in the context of fetal positioning. Sacral counterpressure is a more direct approach for this situation.

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Correct Answer is C

Explanation

The correct answer is C. Hypotension.

A. Respiratory depression is not a common complication of epidural anesthesia. It is more associated with opioid analgesics or excessive administration of other anesthetics.

B. Tachycardia is generally not associated with epidural anesthesia. It is more commonly observed in response to pain or anxiety.

C. Hypotension is a common complication of epidural anesthesia.

Epidural anesthesia can cause vasodilation, leading to a decrease in blood pressure. This is particularly common when the block is administered rapidly or with a higher dose.

D. Vomiting is not a direct complication of epidural anesthesia. Nausea and vomiting are more commonly associated with opioid analgesics or general anesthesia.

A. Just above the umbilicus B. Just above the symphysis pubis C. The right lower quadrant D. The left lower quadrant

Correct Answer is B

Explanation

The correct answer is B. Just above the symphysis pubis.

A. Just above the umbilicus: At the end of the first trimester, the uterus is still within the pelvic cavity, and fetal heart tones are typically not detectable above the umbilicus at this stage.

B. Just above the symphysis pubis: This is the correct placement for assessing fetal heart tones during the first trimester. The fetal heart is usually located low in the pelvis during early pregnancy, making it most easily heard just above the pubic bone.

C. The right lower quadrant: Fetal heart tones are typically assessed in the midline of the abdomen, and focusing on the lower quadrants may not be the optimal location, especially in the first trimester.

D. The left lower quadrant: Similar to the right lower quadrant, focusing on the lower quadrants may not be the most appropriate location for assessing fetal heart tones during the first trimester.

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A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?

Nursing Test Bank

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A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

Correct Answer is C

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