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Pain management: ATI quiz #2

Sources of pain during the stages of labor
1st stage: internal visceral pain that may be felt as back and leg pain

2nd stage: pain that is somatic and occurs with fetal descent and expulsion

3rd stage: pain with the expulsion of the placenta is similar to the pain experienced during the first stage

4th stage: pain is caused by distention and stretching of the vagina and perineum incurred during the second stage with a splitting, burning, and tearing sensation

Indications of pain
1) Behavioral manifestations such as crying, moaning, screaming, gesturing, writhing, avoidance or withdrawal, and inability to follow directions.

2) Increased BP, tachycardia, and hyperventilation

Non-pharmacological pain management
Gate-control theory of pain assists in the understanding of how nonpharmacological pain techniques can work to relieve pain
Sensory stimulation strategies (based on gate-control theory) to promote relaxation and pain relief
1) aromatherapy
2) breathing techniques
3) imagery
4) music
5) use of focal points
6) subdued lighting
Cutaneous strategies (based on gate-control theory) to promote relaxation and pain relief
1) back rub and massage
2) effleurage (light, gentle circular stroking of client’s abd w/ fingertips in rhythm w/ breathing during contractions)
3) sacral counter-pressure (re applied by support person using heel of hand or fist against client’s sacral area to counteract pain in lower back)
4) heat or cold therapy
5) hydrotherapy (whirlpool or shower) increases maternal endorphin levels
6) acupressure
Pharmacological pain management
Include analgesia and local/regional analgesics. Alleviates pain sensation or raises the threshold for pain perception. Analgesia include opioid analgesics.
Sedatives (barbiturates), such as secobarbital (Seconal), pentobarbital (Nembutal), and phenobarbital (Luminal), are not typically used during birth, but they can be used during the early or latent phase of labor to relieve anxiety and induce sleep.
Opioid analgesics
Such as meperidine hydrochloride (Demerol), fentanyl (Sublimaze), butorphanol (Stadol), and nalbuphine (Nubain), act in the CNS to decrease the perception of pain without the loss of consciousness. The client may be given opioid analgesics IM or IV, but IV route is recommended during labor because the action is quicker!

Buorphanol (Stadol) and nalbuphine (Nubain) provide pain relief without causing significant respiratory depression in the mother or fetus. Both IM and IV routs are used.

Epidural and spinal region analgesia consists of…
fentanyl (Sublimaze) and sufentanil (Sufenta), which are short-acting opioids that are administered as a motor block into the epidural or intrathecal space without anesthesia. Theses opioids produce regional analgesia providing rapid pain relief while still allowing the client to sense contractions and maintain the ability to bear down.
Pharmacological anesthesia: regional blocks, epidural blocks & spinal blocks
Eliminates pain perception by interrupting the nerve impulses to the brain. This includes regional blocks and local anesthesia.
Regional blocks
Pudendal block consists of a local anesthetic, such as lidocaine (Xylocaine) or bupivacaine (Marcaine), being administered transvaginally into the space in front of the pudendal nerve.
Epidural blocks
Consists of local anesthetic, bupivacain (Marcaine), along with analgesic, morphine (Duramorph) or fentanyl (Sublimaze), injected into the epidural space at the level of the 4th or 5th vertebrae
Spinal blocks
Consists of local anesthetic that is injected into the subarachnoid space into the spinal fluid at the 3rd, 4th, 5th lumbar interspace. This can be done alone or in combination with an analgesic such as fentanyl (Sublimaze). The spinal block eliminates all sensation from the level of the nipples to the feet. It is commonly used for cesarean births. A low spinal block may be used for vaginal births, but it not used for labor. A spinal block is administered in the late second stage or before cesarean birth.
General anesthesia
Is rarely used for vaginal or cesarean births when there are o complications present. It is used only in the event of a delivery complication or emergency when there is a contraindication to nerve block analgesia or anesthesia. General anesthesia produces unconsciousness.
A nurse is caring for a client at 40 weeks of gestation who is experiencing contractions every 3 to 5 ins and becoming stronger. A vaginal exam reveals that the client’s cervix is 3 cm dilated, 80% effaced, and -1 station. The client ask for pain medication. Which of the following actions should the nurse take at this time? (Select all that apply)

A. Encourage the use of patterned breathing techniques
B. Insert an indwelling urinary catheter
C. Administer opioid analgesic medication as prescribed
d. Suggest application of cold
E. Provide ice chips

A. Encourage the use of patterned breathing techniques
Rationale: To assist with pain management at this time

C. Administer opioid analgesic medication as prescribed
Rationale: Can safely be administered at this time

D. Suggest application of cold
Rationale: The use of nonpharmacological approach, such as the application of cold, is an appropriate intervention at this time

A nurse is caring for a client who is in active labor. The client reports lower back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions is appropriate.

A. Abdominal effleurage
B. Sacral counterpressure
C. Showing if not contraindicated
D. Back rub and massage

B. Sacral counterpressure

Rationale: Sacral counterpressure to the lower back relieves the pressure exerted on the pelvis and spinal nerves by the fetus

A nurse is caring for a client following the administration of an epidural block and is preparing to administer a prescribed IV fluid bolus. The client’s partner asked about the purpose of the IV fluids. Which of the following is an appropriate response by the nurse?

A. “It is needed to promote increased urine output.”
B. “It is needed to counteract respiratory depression.”
C. “It is needed to counteract hypotension.”
D. “It is needed to prevent oligohydramnios.”

C. “It is needed to counteract hypotension.”

Rationale: Maternal hypotension can occur following an epidural block and can be offset by administering an IV fluid blous

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. The client’s labor has been progressing, and she is expected to deliver vaginally in 20 min. The provider is preparing to administer liocaine (Xylocaine) for pain relief and perform an episiotomy. The nurse should know that the type of regional anesthetic block that is to be administered is which of the following?

A. Pudendal block
B. Epidural block
C. Spinal block
D. Paracervical block

A. Pudendal block

Rationale: A pudendal block is a transvaginal injection of local anesthetic that anesthetizes the perineal area for the episiotomy and repair, and the expulsion of the fetus.

A nurse in the labor and delivery unit is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take?

A. Administer oxygen via nasal cannula at 2 L/min
B. Apply a warm blanket
C. Assist the client to a side-lying position
D. Place an oxygen mask over the client’s nose and mouth

D. Place an oxygen mask over the client’s nose and mouth

Rationale: The client is experiencing hyperventilation caused by low serum levels of PCO2. Placing an oxygen mask over the client’s nose and mouth or having the client breath into a paper bag will reduce the intake of oxygen, allowing the PCO2 to rise and alleviate the numbness and tingling.

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