The perinatal nurse is assessing a 36-year-old woman at term who ...

[wenmo]

The perinatal nurse is assessing a 36-year-old woman at term who is in early labor. The nurse assesses for findings that indicate pain, including which of the following? (Select all that apply.)
 
  A.
  Blood pressure: 100/64 mm Hg
  B.
  Frequent voiding in small amounts
  C.
  Increased irritability related to repeated questions
  D.
  Pulse rate of 106 beats per minute
  E.
  Verbalizing concern with coping ability

Question 2

A pregnant woman is asking about a combined spinal-epidural analgesia for labor pain. What information about this method of analgesia should the nurse provide?
 
  A.
  Cannot be used if a cesarean birth is required
  B.
  Causes a total loss of muscle control
  C.
  Associated with a delayed onset of good pain control
  D.
  Associated with an increased risk of infection and headache

[DHRUVSHAH]

Answer to Question 1

ANS: C, D, E
During the assessment, the nurse may identify physiological and psychological changes that are indicative of maternal pain. These include an increased pulse rate and blood pressure, changes in mood, increased anxiety and stress, marked agitation, confusion, decreased urine output, decreased intestinal motility, and guarding of the target area of discomfort. Frequent voiding in small amounts and a normal blood pressure are not findings consistent with labor pain.

Answer to Question 2

ANS: D
This method requires puncture of the dura and placement of a catheter in the epidural space, so it is associated with a higher incidence of infection and postprocedure headache than other methods. The other options are not associated with the combined analgesia.