Answer to Question 1
4
Rationale:
1. Relaxation, not muscle tightening, should be encouraged. Some relaxation techniques teach clients to tighten and then release muscles to learn the difference between tension and relaxation, but the key is to be as relaxed as possible during contractions.
2. Patterned breathing techniques decrease, not increase, anxiety. Practice of patterned breathing prior to the onset of labor facilitates their use during labor.
3. Although some clients would enjoy a massage therapist during their labor, not all clients enjoy massage, and not all clients have the resources to hire this type of professional for their labor.
4. Progressive relaxation (and all relaxation techniques), when practiced prior to labor, is a valuable tool to facilitate relaxation and therefore decrease anxiety during labor.
Answer to Question 2
1
Rationale:
1. Chills indicate fever, which in turn indicates infection. Prolonged premature rupture of membranes increases the risk of maternal infection, specifically chorioamnionitis. Intrauterine infection can be life-threatening to the fetus or to a neonate. This client requires immediate intervention, including contacting the physician.
2. Premature rupture of membranes is the leakage of amniotic fluid; continued leaking of clear fluid does not indicate the development of further complications.
3. Scheduled medications are important, but when a client is experiencing complications, medications are less important.
4. Although this client has prolonged premature rupture of membranes, there is no indication of any further complications. This client is a low priority.