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Excessive anxiety during labor heightens the patient's sensitivity to pain by increasing
- A. muscle tension.
- B. the pain threshold.
- C. blood flow to the uterus.
- D. rest time between contractions.
Correct Answer: A
Rationale: The correct answer is A: muscle tension. Excessive anxiety can lead to increased muscle tension, which can amplify the perception of pain during labor. Tense muscles can make contractions feel more intense and uncomfortable. Increased anxiety does not directly affect the pain threshold (B), blood flow to the uterus (C), or rest time between contractions (D) in a way that would heighten sensitivity to pain. Thus, choice A is the most appropriate explanation for how anxiety impacts pain perception during labor.
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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 best time to teach nonpharmacologic pain control methods to an unprepared laboring patient is during which stage?
- A. Latent phase
- B. Active phase
- C. Second stage
- D. Transition phase
Correct Answer: A
Rationale: The correct answer is A: Latent phase. This stage is ideal for teaching nonpharmacologic pain control methods as the patient is usually more receptive, relaxed, and able to focus. During the latent phase, contractions are typically mild and irregular, allowing the patient to learn and practice techniques effectively. In contrast, the active phase (choice B) is characterized by increased intensity and frequency of contractions, making it challenging for the patient to concentrate on learning. The second stage (choice C) is the pushing stage, where the focus shifts to pushing efforts rather than learning new techniques. The transition phase (choice D) is the most intense stage of labor, making it difficult for the patient to absorb and apply nonpharmacologic pain control methods effectively.
The labor nurse is developing a plan of care for a patient admitted in active labor with
- A. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). What is the priority nursing action for this patient?
- B. Fetal acoustic stimulation
- C. Assess temperature everyN 2 hRourIs G
- D. Change absorption pads under her hips every 2 hours
Correct Answer: A
Rationale: The correct answer is A: On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). The priority nursing action for this patient is to assess the vital signs. The maternal heart rate, fetal heart rate, blood pressure, and temperature are crucial indicators of the patient's and the fetus's well-being during labor. Monitoring these vital signs helps the nurse detect any abnormalities or signs of distress promptly, allowing for timely intervention.
Choice B, fetal acoustic stimulation, is not the priority at this stage as there are no indications in the question stem that suggest the need for this intervention. Choice C, assessing temperature every 2 hours, is not the priority as the patient's temperature is within normal range on admission. Choice D, changing absorption pads under her hips every 2 hours,
The laboring person is anxious and hurting. What can the nurse do to help the laboring person?
- A. Offer her an epidural.
- B. Encourage frequent position changes.
- C. Explain that she has to care for two other persons.
- D. Tell them to call someone to come sit with them.
Correct Answer: B
Rationale: The correct answer is B because encouraging frequent position changes can help alleviate discomfort during labor by reducing pressure on certain areas and promoting better circulation. This also helps with the progression of labor. Choice A (Offer her an epidural) may be a valid option, but it should not be the first line of intervention for all laboring individuals. Choice C (Explain that she has to care for two other persons) is irrelevant and may increase anxiety. Choice D (Tell them to call someone to come sit with them) does not address the physical discomfort and is not a direct intervention to support the laboring person.
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.