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An 18-year-old pregnant woman, gravida 1, is admitted to the labour and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, “My contractions are so strong that I don’t know what to do.” What should the nurse do?
a. Assess for fetal well-being.
b. Encourage the woman to lie on her side.
c. Disturb the woman as little as possible.
d. Recognize that pain is personalized for each individual.

Each woman’s pain during childbirth is unique and is influenced by a variety of physiological, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labour and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the labouring woman. This patient clearly needs support.


Nursing care measures are commonly offered to women in labour. Which nursing measure reflects application of the gate-control theory?
a. Massaging the woman’s back
b. Changing the woman’s position
c. Giving the prescribed medication
d. Encouraging the woman to rest between contractions

According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques such as massage or stroking, music, focal points, and imagery reduce or completely block the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetical gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the woman’s position, giving prescribed medication, and encouraging rest do not reduce or block the capacity of nerve pathways to transmit pain, according to the gate-control theory


A woman in active labour receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease?
a. Meperidine (Demerol)
b. Promethazine (Phenergan)
c. Sufentanil citrate (Sufenta)
d. Nalbuphine (Nubain)

Sufentanil citrate (Sufenta) is becoming the most commonly used opioid agonist analgesic for women in labour. Meperidine hydrochloride (Demerol) used to be the most commonly used opioid agonist analgesic for women in labour, but it is no longer the preferred choice because other medications have fewer adverse effects. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Nubain is an opioid agonist-antagonist analgesic.


A labouring woman received fentanyl citrate (Sublimaze) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Sublimaze on the neonate?
a. Meperidine (Demerol)
b. Promethazine (Phenergan)
c. Naloxone (Narcan)
d. Nalbuphine (Nubain)

An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Demerol is no longer recommended for use in Canada. Promethazine and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Sublimaze on the neonate.


A woman in labour has just received an epidural block. What is the most important nursing intervention?
a. Limit parenteral fluids.
b. Monitor the fetus for possible tachycardia.
c. Monitor the maternal blood pressure for possible hypotension.
d. Monitor the maternal pulse for possible bradycardia.

The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension.


The nurse should be aware that a plan to achieve adequate pain relief without maternal risk is most effective if which of the following occurs?
a. The mother gives birth without any analgesic or anaesthetic.
b. The mother and family’s priorities and preferences are incorporated into the plan.
c. The primary health care provider determines the best pain relief for the mother and family.
d. The nurse informs the family of all alternative methods of pain relief available in the hospital setting.

The assessment of the woman, her fetus, and her labour is a joint effort of the nurse and the primary health care providers, who consult with the woman about their findings and recommendations. The needs of each woman are different, and many factors must be considered before a decision is made whether pharmacological methods, nonpharmacological methods, or a combination of the two will be used to manage labour pain.


A woman in the active phase of the first stage of labour is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. What should the nurse do?
a. Notify the woman’s physician.
b. Tell the woman to slow the pace of her breathing.
c. Administer oxygen via a mask or nasal cannula.
d. Help her breathe into a paper bag.

This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. This enables her to rebreathe carbon dioxide and replace the bicarbonate ion.


A woman is experiencing intense labour pain in her lower back. Which would be an effective relief measure for this woman?
a. Counterpressure against the sacrum
b. Pant-blow (breaths and puffs) breathing techniques
c. Effleurage
d. Conscious relaxation or guided imagery

Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pant-blow and conscious relaxation or guided imagery are usually helpful for contraction per the gate-control theory. Effleurage is helpful as a method of distraction.


What should the labouring woman be taught if she is receiving an opioid antagonist?
a. Her pain will decrease.
b. Her pain will return.
c. She will feel less anxious.
d. She will no longer feel the urge to push.

The woman should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist. Opioid antagonists, such as Narcan, promptly reverse the central nervous system (CNS) depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labour is more rapid than expected and birth is anticipated when the opioid is at its peak effect.


Women who receive an epidural during labour are at an increased risk for which of the following?
a. Hypertension
b. Hyperthermia
c. Decreased oxytocin requirements
d. Decreased oxygen requirements

The patient receiving an epidural is at risk of hyperthermia. The patient is also at risk for hypotension, not hypertension. There is an increased oxytocin requirement with an epidural. There is an increased oxygen requirement with an epidural.


Which of the following reflects the role of the nurse with regard to informed consent?
a. Inform the patient about the procedure and have her sign the consent form.
b. Act as a patient advocate and provide clarification.
c. Call the physician to see the patient.
d. Witness the signing of the consent form.

Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the woman’s advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the patient about potential risk factors. The physician must be present to explain the procedure to the patient. However, the nurse’s responsibilities go further than simply asking the physician to see the patient


A first-time mother is concerned about the type of medications she will receive during labour. She is in a fair amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics often are used with sedatives for which of the following reasons?
a. “The two together work best for you and your baby.”
b. “Sedatives help the opioid work better, and they also will help relax you and relieve your nausea.”
c. “They work better together so you can sleep until you have the baby.”
d. “This is what the doctor has ordered for you.”

Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two drugs to work together more effectively, but it does not ensure maternal or fetal complications. Sedation may be a related effect of some ataractics, but it is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labour and birth. “This is what the doctor has ordered for you” may be true, but it is not an acceptable comment for the nurse to make.


To help patients manage discomfort and pain during labour, nurses should be aware of which of the following?
a. The predominant pain of the first stage of labour is the visceral pain located in the lower portion of the abdomen.
b. Referred pain is the extreme discomfort between contractions.
c. The somatic pain of the second stage of labour is more generalized and related to fatigue.
d. Pain during the third stage is a somewhat milder version of the second stage.

This pain comes from cervical changes, distension of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labour pain is intense, sharp, burning, and localized. Third-stage labour pain is similar to that of the first stage


Which statement correctly describes the effects of various pain factors?
a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth.
b. Upright positions in labour increase the pain factor because they cause greater fatigue.
c. Women who move around trying different positions are experiencing more pain.
d. Levels of pain-mitigating β-endorphins are higher during a spontaneous, natural childbirth.

Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labour pains. Upright positions in labour usually result in improved comfort and less pain. Moving freely to find a more comfortable position is important for reducing pain and muscle tension


Nurses with an understanding of cultural differences regarding likely reactions to pain are better able to help patients. Women from which of the following ethnic groups would be most likely to be stoic in response to labour pain?
a. Chinese women
b. Arab or Middle Eastern women
c. First Nations women
d. African-Canadian women

First Nations women are often stoic in response to labour pain. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labour pain from the start. They may prefer pain medications. African-Canadian women may express pain openly; use of medications for pain is more likely to vary with the individual.


What should the nurse be aware of with regard to a pregnant woman’s anxiety and pain experience?
a. Even mild anxiety must be acknowledged and treated.
b. Severe anxiety increases tension, which increases pain and fear.
c. Anxiety increases the perception of pain, but it does not affect the mechanism of labour.
d. Women who have had a painful labour will have less anxiety the second time because of increased familiarity.

Anxiety and pain reinforce each other in a bad cycle. Mild anxiety is normal for a woman in labour and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can build sufficiently to slow the progress of labour. Unfortunately, an anxious, painful first labour is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.


Nurses should be aware of which of the following differences that experience can make in relation to labour pain?
a. Sensory pain for nulliparous women often is greater than for multiparous women during early labour.
b. Affective pain for nulliparous women usually is less than that for multiparous women throughout the first stage of labour.
c. Women with a history of substance use experience more pain during labour.
d. Multiparous women have more fatigue from labour and thus experience more pain.

Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous women during the second stage. Women with a history of substance use experience the same amount of pain as those without such a history. Nulliparous women have longer labours and thus experience more fatigue


Where is the emphasis placed in the current practice of childbirth preparation?
a. The Dick-Read (natural) childbirth method
b. The Lamaze (psychoprophylactic) method
c. The Bradley (husband-coached) method
d. Attend childbirth preparation in any or no specific method

Getting expectant parents to class is most important, because preparation increases a woman’s confidence and thus her ability to cope with labour and birth.


When is effleurage most effective?
a. First stage of labour
b. Transition phase of labour
c. Second stage of labour
d. Placental delivery

Effleurage is most effective during the first stage of labour


Maternity nurses often have to answer questions about the many ways people have tried to make the birthing experience more comfortable. Nurses should be aware of which of the following?
a. Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine.
b. Women in labour can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time.
c. Effleurage is permissible, but counterpressure is almost always counterproductive.
d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

Transcutaneous electrical nerve stimulation does help. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks might be more effective than a long soak. Counterpressure can help the woman cope with lower back pain.


What should nurses be aware of with regard to systemic analgesics administered during labour?
a. Systemic analgesics cross the maternal blood–brain barrier as easily as they do the fetal blood–brain barrier.
b. Effects on the fetus and newborn can include decreased alertness and delayed sucking.
c. Intramuscular (IM) administration is preferred over intravenous (IV) administration.
d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

Effects depend on the specific drug given, the dosage, and the timing; however, these can include respiratory depression, decreased alertness, and delayed sucking. Systemic analgesics cross the fetal blood–brain barrier more readily than the maternal blood–brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic.


What should nurses be aware of with regard to nerve block analgesia and anaesthesia?
a. Most local agents are chemically related to cocaine and end in the suffix -caine.
b. Local perineal infiltration anaesthesia is effective when epinephrine is added, but it can be injected only once.
c. A pudendal nerve block is designed to relieve the pain from uterine contractions.
d. A pudendal nerve block, if done correctly, does not significantly lessen the bearing-down reflex.

Most local agents are chemically related to cocaine and end in the suffix –caine, such as lidocaine and chloroprocaine. Injections can be repeated to prolong the anaesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions, and it lessens or shuts down the bearing-down reflex.


What should the nurse be cognizant of with regard to spinal and epidural anaesthesia?
a. It is commonly used for Caesarean births but is not suitable for vaginal births.
b. A high incidence of after-birth headache is seen with spinal blocks.
c. Epidural blocks allow the woman to move freely.
d. Spinal and epidural blocks are never used together.

Headaches may be prevented or mitigated to some degree by a number of methods. Spinal blocks may be used for vaginal births, but the woman must be assisted through labour. Epidural blocks limit the woman’s ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.


A woman in labour is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. Which statement is accurate in relation to this scenario?
a. This method is not used much anymore.
b. This method is likely to be used only in the second stage of labour.
c. This describes an application of nitrous oxide.
d. This describes a preparation for Caesarean birth.

This is an application of nitrous oxide, which could be used in either the first or second stage of labour (or both) as part of the preparation for a vaginal birth.


In assessing a woman for pain and discomfort management during labour, what should the nurse do?
a. Have the woman use a visual analogue scale (VAS) to determine her level of pain.
b. Note drowsiness as a sign that the medications were working.
c. Interpret a woman’s fist-clenching as an indication that she is mad at her physician.
d. Evaluate the woman’s skin turgor to see whether she needs a gentle oil massage.

The VAS is a means of adding the woman’s assessment of her pain to the nurse’s observations. Drowsiness is an adverse effect of medications, not usually (sedatives aside) a sign of effectiveness. The fist-clenching likely is a sign of apprehension that may need attention. Skin turgor, the moistness of the membranes, and the concentration of the urine are signs that help the nurse evaluate hydration.


After a change-of-shift report the nurse assumes care of a multiparous patient in labour. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is referred to as which one of the following?
a. Visceral
b. Referred
c. Somatic
d. Afterpain

As labour progresses, the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates the first stage of labour. This pain originates from cervical changes, distension of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labour. Pain experienced during the third stage of labour or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labour.


Maternal hypotension is a potential adverse effect of regional anaesthesia and analgesia. Which nursing intervention would you use to raise the patient’s blood pressure?
a. Place the woman in a supine position.
b. Perform a vaginal examination.
c. Increase intravenous (IV) fluids.
d. Implement continuous electronic fetal heart monitoring.

Nursing interventions for maternal hypotension arising from analgesia or anaesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman’s legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until both are stable. Placing the patient in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure. Electronic monitoring will not affect maternal hypotension.