A nurse is discussing nonpharmacological pain management during labor with a client.
Which of the following statements by the client indicates an understanding of the teaching?
The temperature of the water should be between 36 to 37 degrees Celsius when using hydrotherapy.
My partner can apply counterpressure to my upper abdomen for 10 seconds at a time.
I should use effleurage when I'm pushing.
I can apply a TENS unit to my lower abdomen to decrease the pain of my contractions.
The Correct Answer is A
Choice A rationale
Hydrotherapy, like immersion in a tub or shower, is a nonpharmacological comfort measure for labor pain management. The therapeutic temperature of the water should indeed be maintained between 36 to 37°C (about 96.8 to 98.6°F). This range ensures the water is comfortably warm, promoting muscle relaxation, reducing pain perception, and avoiding potential maternal hyperthermia or fetal distress due to extreme temperatures.
Choice B rationale
Counterpressure is a technique used to relieve back pain caused by pressure of the fetal occiput against the sacrum, commonly known as "back labor.”. It involves steady, strong pressure applied by a support person to the sacral area or lower back, not the upper abdomen. Applying pressure to the upper abdomen would be ineffective and potentially uncomfortable for the client.
Choice C rationale
Effleurage is a light, rhythmic, stroking massage, often applied to the abdomen, used primarily during contractions in the first stage of labor to promote relaxation and distract from pain. It is generally not used during the pushing phase (second stage), as the client's focus shifts to bearing down and expelling the fetus, making effleurage distracting and ineffective.
Choice D rationale
Transcutaneous Electrical Nerve Stimulation (TENS) involves applying mild electrical currents via electrodes to the skin. During labor, the electrodes are typically placed on the lower back (sacral area) to block pain signals related to contractions as they travel up the spinal cord. Applying the TENS unit to the lower abdomen is not the standard placement for optimal labor pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Soft grunting noises during expiration are a sign of mild to moderate respiratory distress in a newborn. Grunting is the newborn's attempt to keep the alveoli open by increasing Positive End-Expiratory Pressure (PEEP), suggesting decreased lung compliance or insufficient surfactant. This finding requires immediate notification of the provider for evaluation and potential intervention.
Choice B rationale
A positive Babinski reflex, which involves the great toe dorsiflexing and the other toes fanning out upon stroking the sole of the foot, is a normal neurological finding in a newborn and infant. This reflex persists until about 1 to 2 years of age as the central nervous system matures, and therefore does not require reporting.
Choice C rationale
Acrocyanosis, which is pale blue hands and feet with pinkish trunk and mucous membranes, is a common and normal finding in a newborn during the first 24 to 48 hours after birth due to immature peripheral circulation and cold exposure. This peripheral vasoconstriction resolves spontaneously and is not typically reported unless accompanied by central cyanosis.
Choice D rationale
Blood-tinged discharge from the vagina, often called pseudomenstruation, is a normal, transient finding in female newborns. It is caused by the withdrawal of maternal estrogen hormones following birth, leading to a minor sloughing of the uterine endometrium, and does not indicate a pathological condition requiring immediate reporting.
Correct Answer is A
Explanation
Choice A rationale
The umbilical cord stump typically dries, shrivels, and spontaneously separates from the infant's abdomen due to a process similar to dry gangrene (ischemic necrosis) within one to three weeks after birth; therefore, this statement indicates correct understanding of the normal timeline for cord care and healing.
Choice B rationale
A newborn's skin is sensitive and prone to drying, and daily tub baths are unnecessary and may cause skin irritation; sponge baths are used until the cord stump falls off, and then typically only two to three baths per week are recommended initially to maintain skin integrity.
Choice C rationale
The correct procedure for using a bulb syringe is to compress the bulb before insertion into the mouth (or nose) to create the negative pressure, then release the compression slowly to suction mucus; compressing it after insertion would expel air into the baby's mouth instead of suctioning.
Choice D rationale
Placing a baby on their side to sleep increases the risk of the baby rolling onto their stomach, which is associated with an elevated risk of Sudden Infant Death Syndrome (SIDS); the universally recommended safe sleep position is supine (on the back).
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