Which intervention should be incorporated in a plan of care for a ...

[Marty]

Which intervention should be incorporated in a plan of care for a labor client who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam3 cm, 80 effaced, and 0 station presenting part vertex.
 
  a. Augmentation of labor with oxytocin (Pitocin)
  b. AROM
  c. Performing a vaginal exam to denote progress
  d. Preparing the client for epidural administration as ordered by the physician

Question 2

A client who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is:
 
  a. You should come into the office and let the doctor check you.
  b. Acetaminophen is acceptable during pregnancy. You should not take aspirin, however.
  c. Back pain is common at this time during pregnancy because you tend to stand with a sway back.
  d. Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication.

[Sassygurl126]

Answer to Question 1

ANS: D
The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore, augmentation would not be advised as this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided.

Answer to Question 2

ANS: A
A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The client needs to be assessed for preterm labor before providing pain relief.

[Marty]

Thank you

[Sassygurl126]

Happy to help you