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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale

The car seat harness straps should be positioned at or slightly below the baby's shoulders when the car seat is installed rear-facing. Positioning the straps above the shoulders could allow the baby to slide up and out of the harness in a crash due to the forces involved, compromising the restraint system's effectiveness and increasing injury risk.

Choice B rationale

The retainer clip, also called the chest clip, must be positioned at the level of the armpits across the center of the chest or sternum, not the abdomen. This critical placement ensures that the harness straps are kept correctly positioned over the baby's shoulders, preventing the straps from slipping off during a collision and maintaining optimal force distribution across the torso.

Choice C rationale

A 45-degree recline angle for a rear-facing car seat is generally recommended to prevent the infant's head from falling forward, which can compromise the airway, particularly in newborns or infants with poor head control. This specific angle is crucial for maintaining a safe and open airway and is often achieved using built-in level indicators on the car seat base.

Choice D rationale

Current safety recommendations advise keeping a child in a rear-facing car seat as long as possible, typically until they reach the maximum weight or height limit allowed by the car seat manufacturer, which often extends well beyond 12 months of age, frequently up to 2 to 4 years of age, for maximum spinal protection.

A. Body tremors. B. Tachypneic respirations. C. Decreased reflexes. D. Extreme lethargy. E. High-pitched crying.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Body tremors are a key indicator of central nervous system (CNS) hyperirritability, which is a major component of neonatal abstinence syndrome (NAS) following in utero exposure to opioids like heroin. The newborn's immature CNS struggles to adapt after the abrupt cessation of the drug, leading to uncoordinated, jerky movements, exaggerated reflexes, and generalized irritability.

Choice B rationale

Tachypneic respirations (respiratory rate greater than 60 breaths/min) are a common sign of NAS. This occurs due to the dysregulation of the autonomic nervous system and increased metabolic rate associated with the hyperirritable state. Other respiratory signs include flaring, retractions, and frequent yawning or sneezing, reflecting CNS overstimulation.

Choice C rationale

The hyperirritability of the CNS in NAS typically leads to increased and exaggerated reflexes (hyperreflexia), such as a hyperactive Moro reflex, not decreased reflexes. Decreased reflexes would suggest CNS depression, which is characteristic of acute opioid intoxication, not the withdrawal state of NAS.

Choice D rationale

Newborns experiencing NAS are characterized by CNS hyperstimulation, leading to excessive wakefulness, irritability, and an inability to be consoled, often referred to as hyperactivity or agitation. Extreme lethargy and hypoactivity are signs of CNS depression or severe illness, which is contrary to the expected presentation of NAS.

Choice E rationale

The hyper-responsiveness of the newborn's CNS in NAS causes a characteristic high-pitched, non-stop, inconsolable crying. This shrill, distressed cry is due to the sustained state of irritability and neurological overstimulation, representing a significant manifestation of withdrawal symptoms that is distressing to both the newborn and the caregivers.

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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?

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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?