The pregnant client term has in presented in the early phase of labor. She is experiencing abdominal pain and shows signs of growing anxiety about pain. What is the best pain management technique the nurse can suggest at this stage?
Practicing effleurage on the abdomen
Beginning epidural anesthesia
using on opioid antagonist, such aS Butorphanol
Immersing the client in hot water in a pool of Jacuzzi
The Correct Answer is A
A) Practicing effleurage on the abdomen:
It is an excellent non-pharmacological pain management technique that can help distract the mother, reduce anxiety, and alleviate some of the discomfort associated with early labor. It also promotes relaxation and can help manage early labor pain effectively without the need for medications. This technique is easy to perform and can be done by the nurse or the partner, providing emotional support along with pain relief.
B) Beginning epidural anesthesia:
Epidural anesthesia is typically not initiated in the early phase of labor unless there is a specific indication or a desire for significant pain relief early in the process. An epidural is more commonly offered in the later stages of labor, when the pain is more intense and the cervix is further dilated. Starting an epidural too early could expose the mother to unnecessary risks and is generally not recommended unless it's requested or deemed medically necessary.
C) Using an opioid antagonist, such as Butorphanol:
Opioids, including Butorphanol, can have side effects such as drowsiness, nausea, and respiratory depression in both the mother and fetus. These medications are more commonly used in later stages of labor or when more potent pain relief is required. Additionally, opioid antagonists like Butorphanol may not be the best choice for a client who is experiencing anxiety and mild to moderate pain in the early phase, as they may not provide the relaxation and coping support that non-pharmacological methods like effleurage offer.
D) Immersing the client in hot water in a pool or Jacuzzi:
While immersion in water can be a helpful method of pain relief, especially during labor, it is generally recommended in the later stages of labor or when the cervix is dilated enough for water immersion to be safely utilized. Immersion in hot water may not be appropriate for all patients and could potentially lead to risks like overheating or changes in blood pressure. Additionally, the early phase of labor often involves less intense pain, and less invasive methods like effleurage are usually preferred first to manage discomfort and reduce anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","H","I"]
Explanation
Findings that require follow-up:
Uterus boggy at 24 hr postpartum:
A boggy uterus indicates poor uterine contraction, which can lead to postpartum hemorrhage. Effective uterine contraction is crucial to prevent excessive bleeding after delivery, and this finding warrants immediate intervention, such as fundal massage or administering uterotonic medications.
Lochia rubra with foul odor:
Foul-smelling lochia is a sign of potential infection, often indicative of endometritis, which is an infection of the uterine lining. The presence of this odor requires prompt follow-up and possibly antibiotic treatment to prevent further complications.
Elevated temperature (38.3°C/100.9°F) at 24 hr postpartum:
A postpartum fever may indicate infection, such as endometritis or a urinary tract infection (UTI). This fever should be investigated further to determine the cause and appropriate treatment, as untreated infections can lead to serious complications.
Increased heart rate (105/min) at 24 hr postpartum:
Tachycardia in the postpartum period can be a sign of infection or early signs of hemodynamic instability, possibly due to blood loss or infection. Close monitoring is necessary, and the healthcare provider should be notified to evaluate the cause and initiate treatment if necessary.
Correct Answer is ["D","E","I","K"]
Explanation
The newborn's assessment findings that require follow-up:
Temperature 35.7°C (96.3°F) at 2200:
Hypothermia in newborns can lead to cold stress, which increases the risk of respiratory distress and hypoglycemia. The newborn’s temperature should be closely monitored, and warming measures should be initiated to prevent further complications.
Respiratory rate 68/min at 2200:
A respiratory rate above 60 breaths per minute in a newborn is considered tachypnea and can indicate respiratory distress or underlying conditions such as infection. The newborn should be further evaluated to determine the cause of the tachypnea and to ensure proper oxygenation.
Sternal retractions at 2200:
Sternal retractions suggest that the newborn is experiencing increased work of breathing, which is a key sign of respiratory distress. This requires immediate evaluation to assess the severity and identify potential causes, such as respiratory infections or inadequate ventilation.
Coarse rhonchi in bilateral lung fields at 2200:
The presence of coarse rhonchi indicates abnormal breath sounds, often related to fluid retention or infection in the lungs. This finding requires further assessment and possibly interventions to clear the airway and support respiratory function.
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