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An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, 'Please give me something for the pain. I can't take the pain!' What is the priority nursing diagnosis?
- A. Pain related to uterine contractions
- B. Knowledge deficit related to the birth experience
- C. Ineffective coping related to inadequate preparation for labor
- D. Risk for injury related to lack of prenatal care
Correct Answer: A
Rationale: The most important issue for this woman, at this time, is effective pain management.
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A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what associated side effect of this type of regional anesthesia?
- A. Reduced fetal heart rate
- B. Long, intense contractions
- C. Sudden leg cramps
- D. Bladder distention
Correct Answer: D
Rationale: A side effect of an epidural block is urine retention, because the anesthesia interferes with the woman's ability to have an urge to void. The patient may have to be catheterized.
What breathing techniques would the nurse teach the prenatal patient to help her focus during labor in order to reduce pain? (Select all that apply.)
- A. First-stage breathing
- B. Abdominal breathing
- C. Fourth-stage breathing
- D. Modified paced breathing
- E. Patterned paced breathing
Correct Answer: A,B,D,E
Rationale: First-stage breathing includes the techniques of modified paced breathing and patterned paced breathing, which are types of abdominal breathing techniques. These patterns of breathing will help a woman in labor to focus and reduce pain perception. The fourth stage of labor is the woman's recovery stage and does not require a breathing technique.
The nurse who encourages the gate control theory of pain control would advise a woman in labor and her partner to use which nonpharmacological method of pain management?
- A. Slow abdominal breathing
- B. Guided relaxation
- C. Listening to music
- D. Massage
Correct Answer: D
Rationale: According to the gate control theory, stimulating large-diameter nerve fibers temporarily interferes with conduction of impulses through small-diameter fibers. Massage is a technique that stimulates large-diameter fibers and 'closes the gate.'
When caring for the laboring patient, the nurse determines that the fetus is located in the right occiput posterior (ROA). What will the nurse anticipate?
- A. Urinary retention
- B. Severe lower back pain
- C. A shorter labor process
- D. Nausea
Correct Answer: B
Rationale: If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mother's sacrum, resulting in persistent and poorly relieved back pain (back labor). Labor is often longer with this fetal position.
A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds the patient that food and fluids need to be restricted for several hours prior to delivery. What will this prevent?
- A. Nausea and vomiting
- B. Vomiting and aspiration
- C. Abdominal cramping
- D. Intestinal obstruction
Correct Answer: B
Rationale: The major adverse effect of general anesthesia is aspiration of stomach contents.