The pregnant client term has in presented in the early phase of labor. She is experiencing abdominal pain and shows signs of growing anxiety about pain. What is the best pain management technique the nurse can suggest at this stage?
Practicing effleurage on the abdomen
Beginning epidural anesthesia
using on opioid antagonist, such aS Butorphanol
Immersing the client in hot water in a pool of Jacuzzi
The Correct Answer is A
A) Practicing effleurage on the abdomen:
It is an excellent non-pharmacological pain management technique that can help distract the mother, reduce anxiety, and alleviate some of the discomfort associated with early labor. It also promotes relaxation and can help manage early labor pain effectively without the need for medications. This technique is easy to perform and can be done by the nurse or the partner, providing emotional support along with pain relief.
B) Beginning epidural anesthesia:
Epidural anesthesia is typically not initiated in the early phase of labor unless there is a specific indication or a desire for significant pain relief early in the process. An epidural is more commonly offered in the later stages of labor, when the pain is more intense and the cervix is further dilated. Starting an epidural too early could expose the mother to unnecessary risks and is generally not recommended unless it's requested or deemed medically necessary.
C) Using an opioid antagonist, such as Butorphanol:
Opioids, including Butorphanol, can have side effects such as drowsiness, nausea, and respiratory depression in both the mother and fetus. These medications are more commonly used in later stages of labor or when more potent pain relief is required. Additionally, opioid antagonists like Butorphanol may not be the best choice for a client who is experiencing anxiety and mild to moderate pain in the early phase, as they may not provide the relaxation and coping support that non-pharmacological methods like effleurage offer.
D) Immersing the client in hot water in a pool or Jacuzzi:
While immersion in water can be a helpful method of pain relief, especially during labor, it is generally recommended in the later stages of labor or when the cervix is dilated enough for water immersion to be safely utilized. Immersion in hot water may not be appropriate for all patients and could potentially lead to risks like overheating or changes in blood pressure. Additionally, the early phase of labor often involves less intense pain, and less invasive methods like effleurage are usually preferred first to manage discomfort and reduce anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["33"]
Explanation
Given:
Total volume to infuse: 100 mL
Infusion time: 60 minutes
Drop factor of tubing: 20 gtt/mL
To find:
Drip rate (gtt/min)
Step 1: Calculate the total number of drops
Total drops = Total volume x Drop factor
Total drops = 100 mL x 20 gtt/mL = 2000 gtt
Step 2: Calculate the drip rate
Drip rate = Total drops / Infusion time in minutes
Drip rate = 2000 gtt / 60 minutes = 33.33 gtt/min
Step 3: Round to the nearest whole number
33 gtt/min.
Correct Answer is B
Explanation
A) Category I:
Category I fetal heart rate patterns are considered normal and are characterized by a baseline fetal heart rate of 110–160 beats per minute, moderate variability, and the presence of accelerations. The pattern also lacks concerning decelerations. While this client’s fetal heart rate is within the normal baseline range (150 bpm), the presence of occasional variable decelerations indicates that the fetal heart rate pattern does not meet the criteria for Category I.
B) Category II:
Category II includes all fetal heart rate patterns that are not classified as Category I or III. This category represents indeterminate or concerning patterns, which require ongoing assessment and interventions. In this case, the fetal heart rate pattern includes a baseline within the normal range, moderate variability, accelerations, but also occasional variable decelerations. Variable decelerations, particularly when they occur intermittently, are often considered non-reassuring but not immediately concerning if they resolve quickly, placing the pattern in Category II.
C) Uncategorized:
"Uncategorized" refers to situations where the fetal heart rate pattern cannot be classified due to insufficient information or an unclear pattern. This is not applicable here because the nurse has identified sufficient data to classify the pattern.
D) Category III:
Category III patterns are considered abnormal and require prompt intervention. These patterns are characterized by persistent decelerations, such as late decelerations, bradycardia, or variable decelerations that do not resolve with interventions. Since the variable decelerations in this case are occasional and not persistent or severe, this pattern does not meet the criteria for Category III.
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