The nurse is providing care to a patient in the active phase of ...

[serike]

The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurse's priority action for this patient?
 
  a. Ask the patient's labor coach if this is a usual expression of pain for her.
  b. Refer to the patient's chart to determine any orders for pain medication.
  c. Tell the patient that she is disturbing the other laboring patients on the unit.
  d. Encourage the patient to try to suppress her noisiness during contractions.

Question 2

Which client will be most receptive to teaching about nonpharmacologic pain control methods?
 
  a. Gravida 1, para 0, in transition
  b. Gravida 2, para 1, admitted at 8 cm
  c. Gravida 1, para 0, dilated 2 cm, 80 effaced
  d. Gravida 3, para 2, complaining of intense perineal pressure

[14vl19]

Answer to Question 1

ANS: A
Women should be encouraged to express themselves in any way they find comforting, and the diversity of their expressions must be respected. Loud and vigorous expression may be a woman's personal pain coping mechanism, whereas a quiet woman may need medication relief but feels the need to remain stoic. Accepting a woman's individual response to labor and pain promotes a therapeutic relationship. Restraint is difficult because noisy women are challenging to work with and may disturb others.

Answer to Question 2

ANS: C
The latent phase of labor is the best time for intrapartum teaching; the latent phase of labor is the first centimeter of cervical dilation. Clients in the transition phase (8 to 10 cm) are experiencing intense pain and are not receptive to teaching. A multigravida complaining of intense perineal pressure indicates a client whose birth is imminent.

[serike]

Thank you

[14vl19]

No problemo