What is an effective relief measure for a laboring client experiencing back labor and complaining of intense pain in her lower back?
Effleurage.
Pant-blow (breaths and puffs) breathing techniques.
Counterpressure against the sacrum.
Conscious relaxation or guided imagery.
The Correct Answer is C
Choice A rationale:
Effleurage is a gentle massage technique often used in labor to promote relaxation and reduce discomfort. It involves using light, stroking movements over the abdomen or back. While effleurage can be soothing for some women, it may not be as effective for specifically addressing the intense back pain associated with back labor. It is more focused on general relaxation than on targeted pain relief in the sacral region.
Choice B rationale:
Pant-blow (breaths and puffs) breathing techniques are commonly taught in childbirth classes as a way to manage labor pain. They involve using specific patterns of breathing to help control contractions and minimize discomfort. While these techniques can be helpful for some women, they may not be as effective for back labor pain as they are primarily focused on managing the sensations of contractions in the abdomen and uterus. They don't directly address the sacral pain that characterizes back labor.
Choice C rationale:
Counterpressure against the sacrum is a specific technique that can be very effective for relieving back labor pain. It involves applying firm, steady pressure to the lower back, specifically the sacral area, using the hands, a fist, or a tennis ball. This pressure can help to counteract the intense sensations of pain and pressure in the lower back, providing significant relief. The mechanism behind this relief is likely related to:
Gate-control theory: Counterpressure may stimulate other nerve pathways, which can block or reduce pain signals from reaching the brain.
Counteracting pressure: The pressure applied to the sacrum may help to counteract the internal pressure of the baby's head against the sacrum, which can be a major source of back labor pain.
Muscle relaxation: Firm pressure can help to relax tense muscles in the lower back, which can contribute to pain.
Choice D rationale:
Conscious relaxation or guided imagery are techniques that can promote overall relaxation and reduce anxiety during labor. They involve using mental exercises to focus the mind on calming images or sensations. While these techniques can be helpful for some women, they may not be as effective for specifically targeting back labor pain as they are more general relaxation methods that don't directly address the sacral pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Drug/alcohol use: While substance abuse during pregnancy can lead to adverse outcomes such as preterm labor, fetal growth restriction, and birth defects, it is not considered a primary factor in determining high-risk status for this patient. The specific substances involved (cocaine and alcohol) are indeed associated with risks, but they are not as significant as other factors in this case.
Age: The patient's age of 24 is not considered a high-risk factor for pregnancy. Advanced maternal age (typically defined as 35 years or older) is associated with increased risks for chromosomal abnormalities and other complications, but this patient falls below that age threshold.
Family history: Family history of diabetes mellitus, cancer, and neural tube defects can be relevant to pregnancy risk, but in this case, other factors outweigh their significance.
Choice B rationale:
Blood pressure: The patient's blood pressure of 108/70 mm Hg is within the normal range and does not contribute to highrisk categorization. High blood pressure (hypertension) during pregnancy can lead to preeclampsia and other complications, but this patient does not present with hypertension.
Age: As explained in Choice A, the patient's age is not a high-risk factor.
BMI: A BMI of 17 is considered underweight, which can increase the risk of certain pregnancy complications such as preterm birth and low birth weight. However, in this case, other factors are more significant in determining high-risk status.
Choice C rationale:
Family history: The patient's family history of a neural tube defect (NTD) in a close relative is a significant risk factor for NTDs in her own pregnancy. NTDs are serious birth defects that affect the brain and spinal cord, and they can have lifelong implications for the child. This factor alone warrants a high-risk categorization.
BMI: The patient's underweight BMI of 17 further contributes to her high-risk status, as it can increase the likelihood of certain complications as mentioned earlier.
Drug/alcohol abuse: The patient's admission of cocaine and alcohol use, even if occasional, is a concerning factor for pregnancy. Cocaine, in particular, is a potent vasoconstrictor that can negatively impact fetal growth and development. Alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders (FASDs), which can cause a range of physical, cognitive, and behavioral problems.
Choice D rationale:
Age: As explained previously, the patient's age is not a high-risk factor.
BMI: The patient's BMI is a contributing factor, but not the most significant one in this case.
Family history: The patient's family history is relevant, but the presence of a neural tube defect in a close relative is the most significant aspect of her family history in terms of pregnancy risk.
Correct Answer is B
Explanation
Choice A rationale:
Performing a vaginal exam is not the priority intervention for a client experiencing hypotension after an epidural. While a vaginal exam may be necessary to assess cervical dilation and fetal station, it does not address the underlying cause of the client's hypotension.
Additionally, a vaginal exam could potentially worsen the client's hypotension by stimulating the vagus nerve, which can lead to decreased heart rate and blood pressure.
Therefore, it is not the most appropriate initial response in this situation.
Choice B rationale:
Turning the client onto her side is the most appropriate initial response to hypotension after an epidural. This position helps to increase venous return to the heart, which can improve cardiac output and blood pressure.
It also helps to prevent aortocaval compression, which can occur when the pregnant uterus compresses the inferior vena cava, reducing blood flow back to the heart.
By turning the client onto her side, the nurse can quickly and easily address the underlying cause of the hypotension and help to improve the client's hemodynamic status.
Choice C rationale:
Catheterizing the client may be necessary if the client is unable to void spontaneously, but it is not the priority intervention for hypotension after an epidural.
Urinary retention can occur after an epidural, but it is not typically the cause of hypotension in this setting.
Therefore, catheterization would not be the most appropriate initial response.
Choice D rationale:
Decreasing the IV fluid rate may be necessary if the client is experiencing fluid overload, but it is not the priority intervention for hypotension after an epidural.
In fact, decreasing the IV fluid rate could potentially worsen the hypotension by reducing the circulating blood volume.
Therefore, it is not the most appropriate initial response.
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