A patient experiencing back labor complains of intense pain in her lower back.
What would be an effective relief measure specific to back pain?
Guided imagery.
Progressive relaxation.
Slow, deep breathing.
Counterpressure against the sacrum.
The Correct Answer is D
Choice A rationale
Guided imagery is a cognitive-behavioral technique that uses mental focus on a peaceful scene or image to distract from pain. While it can be an effective pain management strategy for some women in labor, it is not specific to the physiological cause of back labor. Back labor pain is caused by the occiput of the fetus pressing against the maternal sacrum, which requires a physical, rather than a psychological, intervention to be most effective.
Choice B rationale
Progressive relaxation is a technique that involves tensing and relaxing different muscle groups throughout the body to relieve tension and promote comfort. Like guided imagery, it is a general pain management technique that can be useful for reducing overall labor discomfort. However, it does not directly address the specific cause of back labor, which is the physical pressure from the fetal head on the sacrum.
Choice C rationale
Slow, deep breathing is a common and effective technique for managing labor pain by promoting relaxation, increasing oxygenation, and distracting the patient. It helps the woman focus and cope with contractions. While beneficial for managing labor pain, it is not a targeted intervention for the intense, localized pressure and pain associated with back labor, which responds better to direct physical pressure.
Choice D rationale
Back labor pain is caused by the occiput of the fetus pressing against the maternal sacrum. Counterpressure is a physical intervention that involves applying firm, steady pressure with the heel of the hand or a fist against the sacral area during contractions. This direct pressure helps to displace the fetal head and counteract the pain, making it a highly effective and specific relief measure for back labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Rupture of the amniotic membranes is a natural part of labor progression and a common procedure for labor induction or augmentation. While it is an important event to note and monitor for potential complications like cord prolapse, it is not a direct contraindication for oxytocin administration unless other signs of fetal or maternal compromise are present.
Choice B rationale
A fetal heart rate of 140 beats per minute with accelerations is considered a normal, reassuring finding. The normal fetal heart rate range is 110-160 beats per minute. Accelerations indicate a healthy fetal response to stimulation and adequate oxygenation. Therefore, this finding would support the continuation of oxytocin, not its discontinuation.
Choice C rationale
Uterine hyperstimulation, defined as more than five contractions in 10 minutes, is a significant complication of oxytocin augmentation. This can lead to fetal distress due to reduced uteroplacental blood flow during contractions. The prolonged and frequent contractions can compromise oxygen delivery to the fetus, necessitating immediate discontinuation of the oxytocin infusion to prevent adverse outcomes.
Choice D rationale
A patient needing to void is a normal physiological need. While the nurse should ensure the patient voids regularly to prevent bladder distention, which can impede fetal descent, it is not an indication to discontinue the oxytocin infusion. This action can be managed without interrupting the medication administration.
Correct Answer is E
Explanation
Choice A rationale
Preeclampsia is a hypertensive disorder of pregnancy that can lead to uteroplacental insufficiency. This condition would most likely cause late decelerations in the fetal heart tracing, as it results in decreased blood flow to the placenta and an inability to compensate during contractions. The tracing is not available, but the choice is being rationalized based on the most likely cause.
Choice B rationale
Placental abruption is the premature separation of the placenta from the uterine wall. This can lead to a variety of fetal heart tracing abnormalities, including severe variable decelerations, late decelerations, or a sinusoidal pattern, often accompanied by uterine hyperactivity. The resulting fetal distress is due to decreased placental surface area for gas exchange.
Choice C rationale
Breech positioning refers to a fetus presenting buttocks or feet first. While it can complicate labor and delivery, it is not a direct cause of a specific fetal heart rate pattern. Fetal heart rate changes in a breech presentation are typically related to cord prolapse or compression during labor, not the position itself.
Choice D rationale
Hypotension in the mother can lead to decreased placental perfusion, as seen with epidural anesthesia. This can cause late decelerations in the fetal heart rate tracing due to uteroplacental insufficiency. It is a common cause of fetal distress but is more directly related to maternal blood pressure than to a specific fetal heart rate pattern.
Choice E rationale
Cord compression is a mechanical issue that obstructs blood flow through the umbilical cord. It is the most common cause of variable decelerations, which are abrupt, visually apparent decreases in the fetal heart rate. The tracing, though not available, would likely show these variable decelerations in this context.
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