Promoting Client Comfort During Labor and Delivery

Promoting Client Comfort During Labor and Delivery Related

Review Promoting Client Comfort During Labor and Delivery related questions and content

A patient presents to the labor and birth area for emergent birth. Vaginal exam reveals that the patient is fully dilated, vertex, +2 station, with ruptured membranes. The patient is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this patient assessment?

  • A. Use contact anesthesia for an epidural and prepare the patient per protocol.
  • B. Tell the patient that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop.
  • C. Assist the patient with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth.
  • D. Call the physician for admitting orders.
Correct Answer: A

Rationale: The correct answer is A because the patient is fully dilated and at +2 station, indicating imminent birth. Administering an epidural at this stage can be risky due to the potential for rapid progression of labor, making it difficult to safely place the epidural. Contact anesthesia is often used in emergent situations for epidural placement. Additionally, preparing the patient per protocol ensures that all necessary steps are followed for the safety and well-being of the patient and the baby.

Choices B and C are incorrect because telling the patient she won't need pain medication is dismissive of her valid request and could lead to unnecessary distress. Assisting with nonpharmacologic methods may not be effective at this point given the patient's extreme apprehension and the advanced stage of labor.

Choice D is incorrect as calling the physician for admitting orders is not the priority in this situation. The immediate focus should be on addressing the patient's request for pain management and ensuring her safety during the birth process.

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The laboring person is using hypnosis for comfort measures. How can the nurse support the person?

  • A. Talk them through the contractions.
  • B. Keep the lights on so that everyone can see.
  • C. Keep the room quiet and dimly lit.
  • D. During the contraction, ask them to rate the pain.
Correct Answer: C

Rationale: The correct answer is C because keeping the room quiet and dimly lit promotes relaxation and helps the person stay focused during hypnosis. Bright lights and noise can be distracting and increase stress levels. Talking them through contractions (Choice A) may disrupt their concentration on hypnosis. Asking them to rate pain during contractions (Choice D) can also be disruptive and may increase anxiety.

What are the side effects of spinal anesthesia? Select one that doesn't apply.

  • A. hypotension
  • B. respiratory depression
  • C. renal damage
  • D. infection
Correct Answer: C

Rationale: The correct answer is C: renal damage. Spinal anesthesia affects the nervous system, not the kidneys. Hypotension and respiratory depression are common side effects due to vasodilation and decreased respiratory drive. Infection can occur due to the invasive nature of the procedure. Renal damage is not a known side effect of spinal anesthesia as it does not directly affect kidney function.

A multipara's labor plan includes the use of jet hydrotherapy during the active phase of labor. What is the priority patient assessment prior to assisting the patient with this request?

  • A. Maternal pulse
  • B. Maternal temperature
  • C. Maternal blood pressure
  • D. Maternal blood glucose level
Correct Answer: B

Rationale: The correct answer is B: Maternal temperature. The priority assessment before using jet hydrotherapy is to check the maternal temperature to ensure it is within normal limits. Elevated temperature can indicate infection, which could be exacerbated by hydrotherapy. Maternal pulse (A), blood pressure (C), and blood glucose level (D) are important assessments but are not the priority before using hydrotherapy. Pulse and blood pressure can be monitored during hydrotherapy, and blood glucose levels are typically not affected by hydrotherapy.

The nurse is teaching a childbirth education class. Which information regarding excessive pain in labor should the nurse include in the session?

  • A. It usually results in a more rapid labor.
  • B. It has no effect on the outcome of labor.
  • C. It is considered to be a normal occurrenc
  • D. It may result in decreased placental perfusion.
Correct Answer: D

Rationale: The correct answer is D because excessive pain in labor can lead to increased maternal stress, which may result in decreased placental perfusion, compromising oxygen and nutrient delivery to the fetus. This can have serious implications for the baby's well-being. Choices A, B, and C are incorrect because excessive pain in labor does not necessarily lead to a more rapid labor, has an effect on the labor outcome by potentially impacting placental perfusion, and is not considered a normal occurrence that should be disregarded.

A patient in active labor is experiencing hypotension after receiving an epidural block. What is the nurse's first action?

  • A. Administer a fluid bolus as prescribed.
  • B. Elevate the patient's legs.
  • C. Place the patient in a side-lying position.
  • D. Notify the anesthesiologist immediately.
Correct Answer: C

Rationale: The correct answer is C. Placing the patient in a side-lying position is the first action because it helps to improve venous return, cardiac output, and blood pressure by increasing blood flow to the heart and brain. This can help alleviate hypotension associated with epidural block. Elevating the legs (choice B) may not be as effective in improving blood flow in this situation. Administering a fluid bolus (choice A) may be necessary but should not be the initial action. Notifying the anesthesiologist (choice D) is important, but addressing the patient's immediate physiological needs should come first.

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