Author Question: The nurse assesses a patient in active labor and determines that the fetus is in the left occiput ... (Read 37 times)

OSWALD · **on:** Jun 28, 2018

The nurse assesses a patient in active labor and determines that the fetus is in the left occiput posterior position. The patient indicates to the nurse that she does not want an epidural.

Which is the best technique for the nurse to include in the patient's plan of care?

a. Effleurage
b. Sacral pressure
c. Progressive relaxation
d. Rapid, paced breathing

Question 2

A pregnant client is anticipating a vaginal birth without complications. During the course of her labor, complications arise and the fetus has to be delivered via cesarean section.

The client is visibly upset and wants to know why this has happened to her because she did everything right during her pregnancy. Which priority nursing diagnosis would apply?

a. Risk for injury
b. Pain
c. Impaired skin integrity
d. Anxiety

aham8f · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
The fetus in the occiput posterior position will place pressure against the sacral area. Firm pressure against the sacral area may help relieve strain on the sacroiliac joint from a fetal occiput posterior position (often called back labor). The partner begins to increase pressure on the sacrum as soon as the contraction begins. Effleurage is the slow massage of the abdomen; it does not focus on the sacral area. Progressive relaxation involves contracting and then consciously releasing different muscle groups. The exercise is repeated throughout the body until all voluntary muscles are relaxed. It does not focus on the sacral area. Rapid, paced breathing techniques are used during the transitional phase of labor and are not specifically focused on the sacral area.

Answer to Question 2

ANS: D
Although risk for injury, pain, and impaired skin integrity apply as nursing diagnoses, the client situation is such that she was anticipating a vaginal birth. Thus, she is more likely to be experiencing anxiety related to the change in birth plan so the nurse should respond to that as the priority need.