A nurse is discussing nonpharmacological pain management during labor with a client.
Which of the following statements by the client indicates an understanding of the teaching?
The temperature of the water should be between 36 to 37 degrees Celsius when using hydrotherapy.
My partner can apply counterpressure to my upper abdomen for 10 seconds at a time.
I should use effleurage when I'm pushing.
I can apply a TENS unit to my lower abdomen to decrease the pain of my contractions.
The Correct Answer is A
Choice A rationale
Hydrotherapy, like immersion in a tub or shower, is a nonpharmacological comfort measure for labor pain management. The therapeutic temperature of the water should indeed be maintained between 36 to 37°C (about 96.8 to 98.6°F). This range ensures the water is comfortably warm, promoting muscle relaxation, reducing pain perception, and avoiding potential maternal hyperthermia or fetal distress due to extreme temperatures.
Choice B rationale
Counterpressure is a technique used to relieve back pain caused by pressure of the fetal occiput against the sacrum, commonly known as "back labor.”. It involves steady, strong pressure applied by a support person to the sacral area or lower back, not the upper abdomen. Applying pressure to the upper abdomen would be ineffective and potentially uncomfortable for the client.
Choice C rationale
Effleurage is a light, rhythmic, stroking massage, often applied to the abdomen, used primarily during contractions in the first stage of labor to promote relaxation and distract from pain. It is generally not used during the pushing phase (second stage), as the client's focus shifts to bearing down and expelling the fetus, making effleurage distracting and ineffective.
Choice D rationale
Transcutaneous Electrical Nerve Stimulation (TENS) involves applying mild electrical currents via electrodes to the skin. During labor, the electrodes are typically placed on the lower back (sacral area) to block pain signals related to contractions as they travel up the spinal cord. Applying the TENS unit to the lower abdomen is not the standard placement for optimal labor pain relief.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Fundal massage is the primary intervention for uterine atony and postpartum hemorrhage to stimulate uterine contraction and tamponade bleeding. However, an amniotic fluid embolism (AFE) is characterized by sudden cardiopulmonary collapse, hypoxia, and coagulopathy, where fundal massage is irrelevant to the underlying pathology.
Choice B rationale
AFE involves the sudden entry of amniotic fluid into the maternal circulation, triggering a massive anaphylactoid reaction, acute respiratory distress, and severe refractory hypotension, leading to cardiac and respiratory arrest. Initiating cardiopulmonary resuscitation (CPR) is often immediately required to support life functions.
Choice C rationale
Assisting the client to empty their bladder may be beneficial during labor to allow the fetal head to descend, but it is not a priority intervention for the life-threatening, acute physiological crisis of an AFE. The immediate focus must be on optimizing oxygenation, circulation, and treating the underlying shock and coagulopathy.
Choice D rationale
AFE causes severe pulmonary vasoconstriction and acute respiratory distress, leading to profound hypoxemia. Applying oxygen at 2 L/min via nasal cannula is insufficient for this level of respiratory compromise; the client requires high-flow oxygen, often nonrebreather mask or mechanical ventilation, to maintain adequate arterial oxygen saturation.
Correct Answer is C
Explanation
Step 1 is: Start with the first day of the last menstrual period (LMP): July 21st.
Step 2 is: Subtract 3 months: July minus 3 months is April.
Step 3 is: Add 7 days to the LMP day: 21 plus 7 days is the 28th.
Step 4 is: Add 1 year: April 28th of the following year. Final calculated answer: April 28th.
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