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 A
Explanation
Choice A rationale:
Fetal heart rate of 90 beats per minute is a sign of fetal bradycardia, which is a serious and potentially life-threatening condition. It indicates that the fetus is not getting enough oxygen, and it can lead to fetal distress, brain damage, or even death.
Oxytocin can cause uterine hyperstimulation, which can reduce blood flow to the placenta and cause fetal bradycardia. Therefore, if the nurse observes a fetal heart rate of 90 beats per minute, it is essential to discontinue the oxytocin infusion immediately and notify the healthcare provider.
Choice B rationale:
Increased urinary output is not a direct contraindication to oxytocin administration. In fact, oxytocin can sometimes cause a decrease in urinary output due to its antidiuretic effects.
While a significant increase in urinary output could be a sign of fluid overload, it would not necessarily indicate that the oxytocin infusion needs to be discontinued. The nurse would need to assess the patient's overall fluid status and other clinical indicators to make this determination.
Choice C rationale:
Three contractions occurring within a 10-minute period is considered a normal contraction pattern during labor. It is not a sign of uterine hyperstimulation or fetal distress.
In fact, the goal of oxytocin administration is to achieve regular contractions that are occurring every 2-3 minutes and lasting 40-60 seconds. Therefore, this finding would not indicate that the oxytocin infusion needs to be discontinued.
Choice D rationale:
Adequate resting tone of the uterus palpated between contractions is a normal finding during labor. It indicates that the uterus is contracting effectively and is not at risk for uterine atony (lack of muscle tone).
This finding would not be a reason to discontinue the oxytocin infusion.
Correct Answer is A
Explanation
Choice A rationale:
Misoprostol (Cytotec) is a medication used to induce labor.
It is placed in the posterior vaginal fornix.
However, it should not be used if the woman’s water has broken.
If the amniotic sac has ruptured, using Misoprostol can increase the risk of infection for both the mother and the baby.
Therefore, the statement “I can receive the Cytotec as long as my water hasn’t broken yet” indicates a need for further education.
Choice B rationale:
Walking can indeed help to speed up labor by using gravity to help the baby descend.
However, once Misoprostol has been administered, the woman is usually asked to lie on her side for about 30 to 40 minutes to allow the medication to be absorbed.
After that, if the healthcare provider agrees, she may be able to walk around.
Choice C rationale:
Monitoring the baby’s heart rate and the woman’s contraction pattern is a standard procedure during labor and delivery.
This allows the healthcare team to ensure the safety of both the mother and the baby.
It is especially important when medications like Misoprostol are used, as they can cause changes in the frequency and strength of contractions.
Choice D rationale:
Nausea and vomiting are potential side effects of Misoprostol.
However, not all women experience these side effects, and if they do occur, they are usually temporary.
The healthcare provider can offer solutions to manage these side effects if they become bothersome.
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