A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Encourage the client to rest between contractions.

Massage the client's back.

Turn the client onto her left side.

Administer prescribed analgesic medication.

Answer and Explanation

The Correct Answer is B

B. Massage can stimulate large-diameter nerve fibers that carry non-painful sensations (such as touch and pressure). Activation of these fibers can help close the gate, reducing the transmission of painful stimuli from smaller pain fibers. Therefore, massaging the client's back aligns with the Gate Control Theory by modulating sensory input to the spinal cord.

A. This action can help distract the client from pain and reduce anxiety, which can potentially close the "gate" and decrease the perception of pain. By promoting relaxation and rest, the nurse may indirectly influence the gating mechanism to inhibit pain signals.

C. Positioning the client can be beneficial during labor for various reasons, such as improving blood flow and easing the labor process. While specific lateral positioning (like the left side) may not directly relate to the Gate Control Theory, it can contribute to overall comfort and relaxation, which can influence pain perception indirectly.

D. While analgesic medication can effectively relieve pain, it operates primarily through chemical modulation of pain receptors and pathways in the nervous system. It does not directly interact with the gate mechanism described by the Gate Control Theory. However, by reducing the intensity of pain signals reaching the brain, it can still alleviate pain experienced by the client.

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Correct Answer is C

Explanation

C. Breathing into a paper bag can help the client rebreathe some of the exhaled CO2, which can help correct respiratory alkalosis caused by hyperventilation. This intervention helps increase the CO2 levels in the blood and alleviate symptoms such as lightheadedness and tingling.

A. Instructing the client to increase her respiratory rate would exacerbate the hyperventilation and is not appropriate. This action would further decrease the carbon dioxide (CO2) levels in the blood, worsening symptoms such as lightheadedness and tingling.

B: Administering oxygen is not indicated for hyperventilation because the client's oxygen levels are typically normal in this situation. Oxygen therapy does not address the underlying cause, which is respiratory alkalosis due to excessive CO2 loss. Therefore, it would not alleviate the client's symptoms.

D. Tucking the chin to the chest is not relevant to addressing hyperventilation or its symptoms. This action is more associated with techniques like chest breathing rather than addressing the respiratory alkalosis associated with hyperventilation.

A. Displaced fundus from the midline B. Fundal height below the umbilicus C. Increased urine output D. Decreased urge to void

Correct Answer is A

Explanation

A. After childbirth, the uterus undergoes involution, which is the process of returning to its pre-pregnancy size and position. A displaced fundus from the midline could indicate uterine atony (failure of the uterus to contract), which can lead to postpartum hemorrhage. This finding requires immediate intervention, as postpartum hemorrhage is a significant concern and can be life-threatening if not promptly managed.

B. It is normal for the uterine fundus to gradually descend in the days following childbirth. However, the fundal height being below the umbilicus on the first day postpartum is expected as involution progresses. It does not typically require immediate intervention unless accompanied by other signs of uterine atony or excessive bleeding.

C. Increased urine output is generally a positive finding postpartum, as it indicates the resolution of fluid retention that commonly occurs during pregnancy. It helps prevent postpartum fluid overload and supports the body's adjustment to postpartum changes. This finding does not require immediate intervention unless it is excessive and suggestive of a diuresis that leads to dehydration.

D. Postpartum women may experience decreased urge to void initially due to perineal discomfort, fear of pain, or the effects of anesthesia. However, if the decreased urge persists and leads to inadequate urine output, it could indicate urinary retention, which requires assessment and intervention to prevent bladder distension and potential urinary tract complications.

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A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

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