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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["C","E","H","I"]

Explanation

Findings that require follow-up:

Uterus boggy at 24 hr postpartum:

A boggy uterus indicates poor uterine contraction, which can lead to postpartum hemorrhage. Effective uterine contraction is crucial to prevent excessive bleeding after delivery, and this finding warrants immediate intervention, such as fundal massage or administering uterotonic medications.

Lochia rubra with foul odor:

Foul-smelling lochia is a sign of potential infection, often indicative of endometritis, which is an infection of the uterine lining. The presence of this odor requires prompt follow-up and possibly antibiotic treatment to prevent further complications.

Elevated temperature (38.3°C/100.9°F) at 24 hr postpartum:

A postpartum fever may indicate infection, such as endometritis or a urinary tract infection (UTI). This fever should be investigated further to determine the cause and appropriate treatment, as untreated infections can lead to serious complications.

Increased heart rate (105/min) at 24 hr postpartum:

Tachycardia in the postpartum period can be a sign of infection or early signs of hemodynamic instability, possibly due to blood loss or infection. Close monitoring is necessary, and the healthcare provider should be notified to evaluate the cause and initiate treatment if necessary.

A. Decrease the client's IV fluids B. Prepare the client for an emergent birth. C. Turn the client to a supine position D. Document the findings.

Correct Answer is B

Explanation

A) Decrease the client's IV fluids:
Sinusoidal fetal heart rate patterns are concerning and typically indicate severe fetal distress, which is often associated with conditions such as fetal anemia, hypoxia, or central nervous system (CNS) damage. Decreasing IV fluids is not an appropriate response to a sinusoidal pattern. The primary focus should be on fetal well-being, not fluid management, in this situation.

B) Prepare the client for an emergent birth:
This pattern is typically associated with severe fetal compromise and is an ominous sign. Immediate intervention is required, and emergent delivery may be necessary to prevent further fetal distress and potential harm. The nurse should promptly notify the healthcare provider and prepare the client for an emergency cesarean delivery or other urgent interventions.

C) Turn the client to a supine position:
The supine position is not recommended for managing fetal distress, as it may decrease uterine blood flow and worsen the situation, especially if the fetus is experiencing hypoxia. The appropriate intervention for addressing a sinusoidal heart rate pattern is not repositioning the client in a supine position, but rather preparing for emergency delivery and providing immediate support to stabilize both mother and fetus.

D) Document the findings:
While it is important to document any fetal heart rate pattern, sinusoidal patterns require immediate action. Documentation alone is not sufficient in this case, as it does not address the potential life-threatening situation for the fetus. The nurse should not delay action, and the focus should be on preparing for emergency birth and notifying the healthcare provider immediately.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","E","H","I"]

Explanation

A nurse is analyzing a fetal heart monitor strip and identifies a sinusoidal fetal heart rate pattern, which has been occurring for 30 min. Which of the following actions should the nurse take at this time?

Correct Answer is B

Explanation

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The nurse asks a laboring client to lie on her left side. The appropriate rationale for this measure is to:

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