Exam 2 - Chapter 17 Flashcards
An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, “My contractions are so strong, I don’t know what to do.” The nurse should: 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
D - Each woman’s pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth.
A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively; she states that she did not attend childbirth classes. The most important nursing action is to:
a.
Notify the woman’s health care provider
b.
Administer the prescribed narcotic analgesic
c.
Assure her that her labor will be over soon
d.
Assist her with simple breathing and relaxation instructions
D - By reducing tension and stress, focusing and relaxation techniques allow the woman in labor to rest and conserve energy for the task of giving birth. For those who have had no preparation, instruction in simple breathing and relaxation can be given in early labor and often is successful.
The nurse can perform many functions in labor and birth independently, such as teaching and support.
Pain medication may be an option for this client. However, the initial response of the nurse should include educating the client about her options.
The length of labor varies among individuals, but the first stage of labor is the longest. At 3 cm of dilation with contractions every 5 minutes, this woman has a significant amount of labor yet to experience.
Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? a. Massage the woman’s back. b. Change the woman’s position. c. Give the prescribed medication. d. Encourage the woman to rest between contractions.
A - 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 hypothetic 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 does not reduce or block the capacity of nerve pathways to transmit pain using the gate-control theory.
Pain medication does not reduce or block the capacity of nerve pathways to transmit pain using the gate-control theory.
Resting between contractions does not reduce or block the capacity of nerve pathways to transmit pain using the gate-control theory.
Breathing patterns are taught to laboring women. Which breathing pattern would the nurse support for the woman and her coach during the latent phase of the first stage of labor if the couple had attended Lamaze classes? a. Slow-paced breathing b. Deep abdominal breathing c. Modified-paced breathing d. Patterned-paced breathing
A - Slow-paced breathing is approximately half the woman’s normal breathing rate. It is used during the early stages of labor when a woman can no longer walk or talk through her contractions.
No such pattern as deep abdominal breathing exists in Lamaze.
Modified-paced breathing is shallow breathing that is twice the woman’s normal breathing rate. It is used when labor progresses and the woman can no longer maintain relaxation through paced breathing.
Patterned-pace breathing is a fast, 4:1 breathe, breathe, breathe, blow pattern that is used during the transitional phase of labor just before pushing and delivery.
A laboring woman received meperidine (Demerol) IV 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of meperidine on the neonate? a. Fentanyl (Sublimaze) b. Promethazine (Phenergan) c. Naloxone (Narcan) d. Nalbuphine (Nubain)
C - 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 can promptly reverse the CNS depressant effects, especially respiratory depression.
Fentanyl (Sublimaze) does not act as opioid antagonists to reduce the postnatal effects of meperidine on the neonate.
Promethazine (Phenergan) does not act as opioid antagonists to reduce the postnatal effects of meperidine on the neonate.
Nalbuphine (Nubain) does not act as opioid antagonists to reduce the postnatal effects of meperidine on the neonate.
A nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if:
a.
The mother gives birth without any analgesic or anesthetic
b.
The mother’s priorities and preferences are incorporated into the plan
c.
The primary health care provider decides 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
B - Current evidence indicates that a woman’s satisfaction with her labor and birth experience is determined by how well her personal expectations of childbirth are met and the quality of support and interaction she receives from her caregivers. The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers, who consult 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 pharmacologic methods, nonpharmacologic methods, or a combination of the two will be used to manage labor pain.
Although the predominant medical approach to labor is that it is painful, and the pain must be removed, an alternative view is that labor is a natural process, and women can experience comfort and transcend the discomfort or pain to reach the joyful outcome of birth. The provider should collaborate with the mother and her support persons as to the ideal plan to achieve adequate pain relief.
The most helpful interventions in enhancing comfort are a caring nursing approach and a supportive presence. Discussing options for nonpharmacologic methods of pain relief is also helpful. Ideally this is done prior to the onset of labor.
If an opioid antagonist is administered to a laboring woman, she should be told: 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
B - Opioid antagonists such as naloxone (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 labor is more rapid than expected, and birth is anticipated when the opioid is at its peak effect. The woman should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist.
The woman should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist. Her pain level will increase rather than decrease.
Opioid antagonists have no effect on anxiety levels. They are given primarily to reverse excessive CNS depression in the mother, newborn, or both.
An opioid antagonist (e.g., naloxone) has no effect on the mother’s urge or ability to push. The practice of giving lower doses of IV opioids has reduced the incidence and severity of opioid-induced CNS depression; therefore, opioid antagonists are used less frequently.
A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman’s IV fluid for a preprocedural bolus. Prior to initiation of the epidural the woman should be informed regarding the disadvantages of an epidural block. They include all except: a. Ability to move freely is limited b. Orthostatic hypotension and dizziness c. Gastric emptying is not delayed d. Higher rate of fever
C - This is an advantage of an epidural block. Other advantages include the woman remains alert and able to participate, good relaxation is achieved, airway reflexes remain intact, only partial motor paralysis develops and blood loss is not excessive.
The woman’s ability to move freely and to maintain control of her labor is limited, related to the use of numerous medical interventions (IV and electronic fetal monitoring [EFM]).
Significant disadvantages of an epidural block include the occurrence of orthostatic hypotension, dizziness, sedation, and leg weakness.
Women who receive an epidural have a higher rate of fever (38° C or greater) especially when labor lasts longer than 12 hours. This may result in an unnecessary neonatal workup for sepsis.
Your client is in early labor, and you are discussing the pain relief options she is considering. She states that she wants an epidural “no matter what!” Your best response is:
a.
“I’ll make sure you get your epidural.”
b.
“You may only have an epidural if your doctor allows it.”
c.
“You may only have any epidural if you are going to deliver vaginally.”
d.
“The type of analgesia or anesthesia used is determined in part by the stage of your labor and the method of birth.”
D - To avoid suppression of the progress of labor, pharmacologic measures for pain relief generally are not implemented until labor has advanced to the active phase of the first stage and the cervix is dilated approximately 4 to 5 cm.
A plan of care is developed for each woman to address her particular clinical and nursing problems. The nurse collaborates with the primary health care provider and the laboring woman in selecting features of care relevant to the woman and her family. The decision whether to use an epidural to relieve labor pain is multifactorial. The nurse should not make a blanket statement guaranteeing the client one pharmacologic option over another until a complete history and physical examination has been obtained.
A physician’s order is required for pharmacologic options for pain management. However, this is not the nurse’s best response.
An epidural is an effective pharmacologic pain management option for many laboring women. It can also be used for anesthesia control if the woman undergoes an operative delivery.
The role of the nurse with regard to informed consent is to:
a.
Inform the client about the procedure and have her sign the consent form
b.
Act as a client advocate and help clarify the procedure and the options
c.
Call the physician to see the client
d.
Witness the signing of the consent form
B - 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 client about potential risk factors.
The physician must be present to explain the procedure to the client. However, the nurse’s responsibilities go further than simply asking the physician to see the client.
The nurse may witness the signing of the consent form. However, depending on the state’s guidelines, the woman’s husband or another hospital health care employee may sign as witness.
A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair amount of pain and is nauseated. Additionally she appears to be very anxious. You explain that opioid analgesics often are used with sedatives because:
a.
“The two together work the best for you and your baby.”
b.
“Sedatives help the opioid work better, and they 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.”
B - Sedatives may be used to reduce the nausea and vomiting that often accompany opioid use. Additionally, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects.
A potentiator may cause 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 labor and birth.
Although the doctor may have ordered the medications, it is not an acceptable comment for the nurse to make.
In order to help clients manage discomfort and pain during labor, nurses should be aware that:
a.
The predominant pain of the first stage of labor 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 labor is more generalized and related to fatigue
d.
Pain during the third stage is a somewhat milder version of the second stage
A - This pain comes from cervical changes, distention 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 labor pain is intense, sharp, burning, and localized.
Third-stage labor 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 labor 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 beta-endorphins are higher during a spontaneous, natural childbirth.
D - Higher endorphin levels help women tolerate pain and reduce anxiety and irritability.
Higher prostaglandin levels correspond to more severe labor pains.
Upright positions in labor usually result in improved comfort and less pain.
Moving freely to find more comfortable positions is important for reducing pain and muscle tension.
Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help clients. Nurses should know that \_\_\_\_\_ women may be stoic until late in labor, when they may become vocal and request pain relief. a. Chinese b. Arab or Middle Eastern c. Hispanic d. African-American
C - Hispanic women may be stoic early, more vocal and ready for medications later.
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 labor pain from the start. They may prefer pain medications.
African-American women may express pain openly; use of medications for pain is more likely to vary with the individual.
With regard to a pregnant woman’s anxiety and pain experience, nurses should be aware that:
a.
Even mild anxiety must be treated
b.
Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on
c.
Anxiety may increase the perception of pain, but it does not affect the mechanism of labor
d.
Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity
B - Anxiety and pain reinforce each other in a bad cycle.
Mild anxiety is normal for a woman in labor 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 labor.
Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.
Nurses should be aware that all reputable childbirth methods attempt to meet all these goalsexcept: a. Increase the woman’s sense of control b. Prepare a support person to help in labor c. Guarantee a pain-free childbirth d. Learn distraction techniques
C - All methods try to increase a woman’s sense of control, prepare a support person, and train the woman in physical conditioning, which includes breathing techniques. They cannot, and reputable ones do not, promise a pain-free childbirth.
Increasing a woman’s sense of control is the goal of all childbirth preparation methods.
Preparing a support person to help in labor is a vitally important component of any childbirth education program. The coach may learn how to touch a woman’s body to detect tense and contracted muscles. The woman then learns how to relax in response to the gentle stroking by the coach.
Distraction techniques are a form of care that are effective to some degree in relieving labor pain and are taught in many childbirth programs. This includes imagery, feedback relaxation, and attention-focusing behaviors.
Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that:
a.
Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine
b.
Women in labor 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
D - Transcutaneous electrical nerve stimulation (TENS) may help and is most useful for lower back pain that occurs during the first stage of labor.
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.
With regard to nerve block analgesia and anesthesia, nurses should be aware that:
a.
Most local agents are related chemically to cocaine and end in the suffix –caine
b.
Local perineal infiltration anesthesia 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
A - Common agents include lidocaine and chloroprocaine.
Injections can be repeated to prolong the anesthesia.
A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions.
A pudendal nerve block lessens or shuts down the bearing-down reflex.
A woman in labor 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. This procedure is: a. Not used much anymore b. Likely to be used in the second stage of labor but not in the first stage c. An application of nitrous oxide d. A prelude to cesarean birth
C - This is an application of nitrous oxide, which can be used in combination with other nonpharmacologic and pharmacologic measures for pain relief.
This is an application of nitrous oxide mixed with oxygen in a low concentration. It is still commonly used in Canada and the United Kingdom.
Nitrous oxide inhaled in a low concentration will reduce but not eliminate pain during the first and second stages of labor.
Nitrous oxide inhalation is not generally used prior to caesarean birth. Nitrous oxide does not appear to depress uterine contractions or cause adverse reactions in the newborn.
According to professional standards (AWHONN, 2007) the nonanesthetist registered nurse caring for a woman with an epidural is permitted to perform all actions except:
a.
Monitor the status of the woman and fetus
b.
Initiate epidural anesthesia
c.
Replace empty infusion bags with the same medication and concentrate
d.
Stop the infusion and initiate emergency measures
B - Only qualified, licensed anesthesia care providers are permitted to insert a catheter, initiate epidural anesthesia, verify catheter placement, inject medication through the catheter, or alter the medication or medications including type, amount, or rate of infusion.
The nonanesthetist nurse is permitted to monitor the status of the woman, the fetus, and the progress of labor.
Replacement of the empty infusion bags or syringes with the same medication and concentration is permitted.
If the need arises the nurse may stop the infusion, initiate emergency measures, and remove the catheter if properly educated to do so. Complications can require immediate interventions. Nurses must be prepared to provide safe and effective care during the emergency situation.
Conscious relaxation is associated with which method of childbirth preparation? a. Grantly Dick-Read method b. Lamaze method c. Bradley method d. Psychoprophylactic method
A - With the Grantly Dick-Read method, women are taught to consciously and progressively relax different muscle groups throughout the body until a high degree of skill at relaxation is achieved.
The Lamaze method combines controlled muscular relaxation with breathing techniques.
The Bradley method advocates natural labor, without any form of anesthesia or analgesia, assisted by a husband-coach and using breathing techniques for labor.
The psychoprophylactic method is another name for the Lamaze method.
During anesthetic management of the morbidly obese woman in labor, the nurse must remain alert for complications specific to this type of client. Which is not a concern for the L&D nurse? a. Failed epidural placement b. Accidental dural puncture c. Inadequate pain relief d. Difficult intubation
C - Use of regional anesthetic can provide adequate pain management for the obese client during labor and delivery.
Problems may be encountered when positioning the woman and identifying correct landmarks to ensure proper insertion of the epidural.
Due to the difficulty with epidural placement in the obese client, an accidental dural puncture is more likely to occur.
During an emergent delivery, anesthesia providers encounter more complications and difficult intubation in the obese parturient.
