A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
Turn the client onto her left side.
Massage the client's back.
Encourage the client to rest between contractions
Administer prescribed analgesic medication
The Correct Answer is B
The correct answer is B. Massage the client's back.
A. Turning the client onto her left side may be a comfort measure, but it is not specifically associated with the gate control theory of pain. It may help improve blood flow and relieve pressure but does not directly engage the gate control mechanism.
B. Massage the client's back is consistent with the gate control theory of pain.
According to the gate control theory, non-painful input (such as massage) can close the "gate" to painful input, reducing the perception of pain. Massage stimulates large-diameter nerve fibers, which can inhibit the transmission of painful signals.
C. Encouraging the client to rest between contractions is a general comfort measure but is not directly related to the gate control theory of pain.
D. Administering prescribed analgesic medication is a pharmacological approach to pain management and is not specifically associated with the gate control theory. Medications can act on pain receptors but do not engage the gate control mechanism.
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Related Questions
Correct Answer is B
Explanation
A. Administering oxygen at 10 L/min via a nonrebreather mask is an important intervention, but changing the client's position is the priority action when late decelerations are observed. Oxygen administration can follow, but optimizing uteroplacental perfusion through changing position is crucial.
B. Changing the client's position is the correct first action.
Repositioning the client, particularly from a supine to a side-lying position, can help alleviate compression on the vena cava and improve blood flow to the uterus, reducing the likelihood of late decelerations.
C. Applying a fetal scalp electrode is not the initial action when late decelerations are noted. Repositioning the client should be attempted first to address potential issues related to uteroplacental perfusion.
D. Increasing the rate of the intravenous (IV) infusion might not directly address the issue of late decelerations. It's important to focus on maternal positioning first to improve blood flow to the uterus.
Correct Answer is A
Explanation
The correct answer is A. Contractions lasting longer than 90 seconds.
A. Contractions lasting longer than 90 seconds can be indicative of a prolonged contraction, which may affect uteroplacental perfusion and fetal oxygenation. This is a concern and should be reported to the provider.
B. Contractions occurring every 3 to 5 minutes are within the normal frequency range during the active phase of the first stage of labor.
C. The client reporting feeling contractions in the lower back is a common description of back labor, which may occur due to the position of the baby. It is not necessarily a cause for immediate concern unless it is associated with other issues.
D. Contractions being strong in intensity is expected during the active phase of labor. Strong contractions are necessary for cervical dilation and the progression of labor.
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