Ch20: Pain management

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Question 139525Id:139525Question Title:

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Question Stem The laboring patient has rated her pain at 9 on a scale of 110, and she requests IV pain medication. She has refused epidural anesthesia, but her certified nurse-midwife (CNM) has ordered butorphanol tartrate (Stadol) for administration to the patient. Which action should the nurse complete next?

Stimulus

Answer Choice 1Advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.

Rationale 1Prior to administration of medication, the nurse must explain the pharmacologic effects of the medication and obtain consent for administration.

Answer 1true

Choice 2Offer the woman epidural anesthesia once more and describe the effectiveness of this method of labor pain control.

Rationale 2The woman has refused epidural anesthesia but is authorized to receive butorphanol tartrate. The nurses next step is to advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.

Answer 2false

Choice 3Obtain maternal vital signs and assess the fetal heart rate (FHR).

Rationale 3Prior to obtaining maternal vital signs and assessing FHR, the nurse should advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.

Answer 3false

Choice 4Administer oxygen via face mask at 6 to 10 liters per minute.

Rationale 4Routine oxygen administration is not indicated for administration of butorphanol tartrate to an asymptomatic patient in labor. The nurses next step is to advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.

Answer 4false

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Meta 4 Learning Outcome 1:LO01 - Describe the use, administration, dose, onset of action, adverse effects, and contraindications of systemic drugs that promote pain relief during labor in determining the nursing care management of the woman in labor and her fetus.

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Question Stem A patient has just been admitted for labor and delivery. She is having mild contractions every 15 minutes lasting 30 seconds. The patient wants to have a medication-free birth. When discussing medication alternatives, the nurse should be sure the patient understands that:

Stimulus

Answer Choice 1In order to respect her wishes, no medication will be given.

Rationale 1It is important to respect the patients wishes when possible. Once the effects are explained, it is still the patients choice whether to receive medication.

Answer 1false

Choice 2Pain relief will allow a more enjoyable birth experience.

Rationale 2While pain relief can lead to a more enjoyable experience, it might be the view of the nurse but not the mother.

Answer 2false

Choice 3The use of medications allows the patient to rest and be less fatigued.

Rationale 3While pain relief can allow the mother to be less fatigued, it might be the view of the nurse but not the mother.

Answer 3false

Choice 4Maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.

Rationale 4The decision not to medicate should be an informed one, and it is possible that the patient does not know about the effects pain and stress can have on the fetus. Once the effects are explained, it is still the patients choice whether to receive medication.

Answer 4true

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Question Stem The nurse has presented a teaching session on pain relief options to a prenatal class. Which patient statement indicates that additional teaching is needed?

Stimulus

Answer Choice 1An epidural can be continuous or one dose.

Rationale 1Epidural anesthesia can be administered in a single dose or via continuous infusion.

Answer 1false

Choice 2General anesthesia is usually recommended for a patient who delivers by way of cesarean section.

Rationale 2Compared to general anesthesia, spinal anesthesia is usually the anesthetic of choice indicated in the management of patients undergoing cesarean section.

Answer 2true

Choice 3Narcotics can be given through a patients epidural infusion catheter.

Rationale 3To provide analgesia for approximately 24 hours after the birth, the analgesia provider may inject an opioid, such as morphine sulfate (Duramorph) or fentanyl (Sublimaze), into the epidural space immediately after the birth

Answer 3false

Choice 4A pudendal block usually works well to control pain during episiotomy repair.

Rationale 4A pudendal block technique is given in the second stage of labor for the provision of perineal anesthesia for the latter part of the first stage of labor, the second stage, birth, and episiotomy repair.

Answer 4false

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Meta 4 Learning Outcome 1:LO02 - Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, contraindications, techniques, and nursing care management of the laboring woman and her fetus.

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Question Stem The charge nurse is reviewing the plans of care for four laboring patients. Which care plan requires immediate reconsideration for revision?

Stimulus

Answer Choice 1Administration of epidural anesthesia to a woman who is in the first stage of labor and has a shellfish allergy

Rationale 1A lumbar epidural relieves pain associated with the first and second stages of labor. An allergy to shellfish is not a contraindication to epidural anesthesia.

Answer 1false

Choice 2Administration of a spinal anesthetic to a woman who is scheduled for vaginal delivery of her baby

Rationale 2Spinal anesthetics may be used to provide anesthesia for cesarean birth and occasionally for vaginal birth.

Answer 2false

Choice 3Administration of epidural anesthesia to a woman with a history of vomiting secondary to hyperemesis gravidarum

Rationale 3Contraindications to epidural anesthesia include severe hypovolemia of any etiology. This patient with hyperemesis gravidarum should be evaluated for severity of dehydration prior to administration of epidural anesthesia.

Answer 3true

Choice 4Administration of a spinal anesthetic to a woman with a history of irritable bowel syndrome (IBS)

Rationale 4Irritable bowel syndrome (IBS) does not represent a contraindication to spinal anesthesia.

Answer 4false

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Question Stem Which of the following nursing actions can prevent or detect common side effects of epidural anesthesia?

Standard TextSelect all that apply.

Stimulus

Answer Choice 1Preloading the patient with a rapid infusion of IV fluids

Rationale 1Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential.

Answer 1true

Choice 2Continuing the patient on p.o. fluids only to prevent hypotension


Answer 2false

Choice 3Monitoring the FHR for late deceleration and decrease in rate


Answer 3true

Choice 4Use of intermittent FHR monitoring so the patient can use the birthing ball


Answer 4false

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Question Stem Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring patient in which of the following positions?

Stimulus

Answer Choice 1On her right side in the center of the bed with her back curved

Rationale 1Especially in pregnant women, this position is not ideal for facilitating access to the epidural space.

Answer 1false

Choice 2Lying prone with a pillow under her chest

Rationale 2This position is not consistent with access to the epidural spaces.

Answer 2false

Choice 3On her left side with the bottom leg straight and the top leg slightly flexed

Rationale 3This position is not consistent with access to the epidural spaces.

Answer 3false

Choice 4Sitting on the edge of the bed with her back slightly curved and her feet on a stool

Rationale 4Sitting on the edge of the bed with the back slightly curved and the feet on a stool allows the epidural spaces to be accessed more easily.

Answer 4true

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Question Stem The laboring patient requests pain medication. Her contractions are lasting 2030 seconds and are occurring every 820 minutes. The nurse would explain that analgesics given at this time would likely cause:

Stimulus

Answer Choice 1Fetal respiratory depression.

Rationale 1Pain medication given before established labor does not cause fetal respiratory depression unless the mother delivers within an hour of receiving the medication. This is not likely if labor is not established.

Answer 1false

Choice 2Decreased analgesic effectiveness at the end of labor.

Rationale 2Medication given early in the labor process does not become less effective at the end of labor.

Answer 2false

Choice 3Maternal hypotension.

Rationale 3Analgesics might lower the blood pressure, but this effect does not cause the contraction pattern to be altered.

Answer 3false

Choice 4Prolonged labor.

Rationale 4Pain medication given before labor becomes established is likely to prolong the labor process.

Answer 4true

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Question Stem During her hospital admission, the laboring patient explicitly refused all pain medications and a labor epidural. Once dilated to 5 cm, the patient complains of intolerable discomfort and asks the nurse, If I have an epidural, how will you make sure it doesnt hurt my baby? The best response by the nurse is:

Stimulus

Answer Choice 1Well monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural.

Rationale 1Continuous electronic fetal monitoring to assess fetal status is indicated in the care of pregnant women who receive epidural anesthesia and allows for a more direct assessment of fetal status than does frequent monitoring of maternal BP and pulse, which are also indicated in the care of this patient.

Answer 1true

Choice 2Epidural anesthesia is very safe and there are no potential side effects that can affect your baby.

Rationale 2While proficient administration and monitoring of epidural anesthesia allows for a high degree of safety with this technique, maternal hypotension associated with epidural anesthesia may produce harmful fetal effects.

Answer 2false

Choice 3Well assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby.

Rationale 3While frequent monitoring of maternal blood pressure and pulse are indicated in the care of a patient who receives a labor epidural, continuous electronic fetal monitoring is also indicated for assessment of fetal status and allows for a more direct fetal assessment.

Answer 3false

Choice 4Before your epidural is placed, well administer IV fluid to you in order to prevent the epidural from causing you problems.

Rationale 4While administration of a bolus of IV fluid is indicated in preparation for epidural placement and reduces the risk for maternal hypotension, this intervention neither guarantees the prevention of related complications nor allows for assessment of fetal status.

Answer 4false

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Question Stem The anesthesia provider has just administered an epidural anesthetic in a laboring patient and local anesthesia is continuously infusing via the epidural catheter. Suddenly, the patient asks, Why are my ears ringing? What is the most likely cause of the patients complaint?

Stimulus

Answer Choice 1Hypotension

Rationale 1Although maternal hypotension is associated with epidural anesthesia, a sensation of ringing in the ears is associated with local anesthetic toxicity.

Answer 1false

Choice 2Allergic reaction

Rationale 2Sensation of ringing in the ears is associated with local anesthetic toxicity.

Answer 2false

Choice 3Dehydration


Answer 3false

Choice 4Local anesthetic toxicity


Answer 4true

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Question Stem The nurse is caring for a laboring patient who is receiving continuous epidural anesthesia via infusion. The maternal blood pressure decreases from 132/78 to 78/42. Which intervention should the nurse implement first?

Stimulus

Answer Choice 1Increase the flow rate of infusion of intravenous crystalloid solution.

Rationale 1If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.

Answer 1true

Choice 2Verify the patient is positioned to promote left uterine displacement.


Answer 2false

Choice 3Administer oxygen.


Answer 3false

Choice 4Administer ephedrine 5 to 10 mg intravenously.


Answer 4false.

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Question Stem During admission, a laboring patient tells the nurse, Im so afraid Ill need a cesarean section. I dont want to be asleep for surgery when my baby is born! Which of the following nursing responses is most appropriate?

Stimulus

Answer Choice 1If a cesarean section is needed, that doesnt necessarily mean youll need to go to sleep for surgery.

Rationale 1While general anesthesia may be needed for cesarean birth and for surgical intervention with some complications, in modern obstetrics, general anesthesia is used in less than 1% of all obstetric births.

Answer 1true

Choice 2Your anesthesia provider will require that you go to sleep for surgery.

Rationale 2General anesthesia may be needed for cesarean birth and for surgical intervention with some complications. However, in modern obstetrics, spinal anesthesia is often administered for delivery via cesarean section, while general anesthesia is used in less than 1% of all obstetric births.

Answer 2false

Choice 3Well do our best to make sure you deliver vaginally, so you dont need to have a cesarean section.

Rationale 3Reassuring the patient in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section.

Answer 3false

Choice 4If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly.

Rationale 4Reassuring the patient in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section.

Answer 4false

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Question Stem A laboring patient has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, the nurse would expect to do which of the following?

Stimulus

Answer Choice 1Observe fetal heart rate variability.

Rationale 1Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common side effect of an epidural.

Answer 1false

Choice 2Rapidly infuse 5001,000 ml of intravenous fluids.

Rationale 2Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage to the procedure.

Answer 2true

Choice 3Place the patient in the semi-Fowlers position.


Answer 3false

Choice 4Teach the patient appropriate breathing techniques.


Answer 4false

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Question Stem After receiving nalbuphine hydrochloride (Nubain), a womans labor progresses rapidly, and the baby is born less than one hour later. The baby exhibits signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn?

Stimulus

Answer Choice 1Fentanyl (Sublimaze)

Rationale 1Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain.

Answer 1false

Choice 2Butorphanol tartrate (Stadol)


Answer 2false

Choice 3Naloxone (Narcan)


Answer 3true

Choice 4Pentobarbital (Nembutal)


Answer 4false

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Question Stem The patient at 39 weeks gestation is undergoing a Cesarean birth due to breech presentation. General anesthesia is being used. Which potential challenge is most relevant to the anesthesia care of this patient?

Stimulus

Answer Choice 1Hypotension due to the intense blockade of sympathetic fibers

Rationale 1Regional anesthesia, including epidural anesthesia, is associated with an intense blockade of sympathetic fibers that results in a high incidence of hypotension.

Answer 1false

Choice 2Difficulty with maternal intubation

Rationale 2Difficulty with maternal intubation is a primary challenge of general anesthesia care for pregnant patients.

Answer 2true

Choice 3Broad ligament hematoma

Rationale 3Broad ligament hematoma is a complication associated with pudendal blockade.

Answer 3false

Choice 4Fetal depression that is fetal depression inversely proportional to maternal anesthetic depth and duration

Rationale 4Fetal depression associated with general anesthesia is directly proportional to maternal anesthetic depth and duration.

Answer 4false

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Question Stem Following spinal anesthesia for delivery of her baby, a woman reports an inability to void urine. As the nurse palpates the womans bladder the woman says, Its been five hours since I had my spinal and I still cant empty my bladder. Do I have nerve damage? How should the nurse respond?

Stimulus

Answer Choice 1Spinal anesthesia can sometimes cause nerve damage.

Rationale 1Although nerve damage is a rare occurrence in relation to spinal anesthesia, there is no objective data to suggest that this woman has experienced nerve damage. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

Answer 1false

Choice 2It may be several hours before youre able to control your urination.

Rationale 2Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

Answer 2true

Choice 3You should be able to control your bladder by now. Ill ask the anesthesia provider to visit with you.

Rationale 3Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

Answer 3false

Choice 4You are probably dehydrated. Please increase your water intake.

Rationale 4There is no data to suggest the woman is dehydrated. Rather, she is likely demonstrating a common side effect of spinal anesthesia. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

Answer 4false

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Ch20: Pain management

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Transcript of Ch20: Pain management