Perry: Maternal Child Nursing Care, 4th Edition

Chapter 16: Management of Discomfort Test Bank MULTIPLE CHOICE 1. An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, My contractions are so strong that I dont know what to do. The nurse should: a. Assess for fetal well-being. b. Encourage the woman to lie on her side. c. Disturb the woman as little as possible. d. Recognize that pain is personalized for each individual. ANS: D Each womans pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support. PTS: 1 DIF: Cognitive Level: Application REF: 394 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Diagnosis 2. Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? a. Massaging the womans back b. Changing the womans position c. Giving the prescribed medication d. Encouraging the woman to rest between contractions ANS: A According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques such as massage or stroking, music, focal points, and imagery reduce or completely block the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the womans position, giving prescribed medication, and encouraging rest do not reduce or block the capacity of nerve pathways to transmit pain using the gate-control theory.

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PTS: 1 DIF: Cognitive Level: Comprehension REF: 397 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation 3. A woman in active labor receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease? a. Meperidine (Demerol) c. Butorphanol tartrate (Stadol) b. Promethazine (Phenergan) d. Nalbuphine (Nubain) ANS: A Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Stadol and Nubain are opioid agonist-antagonist analgesics. PTS: 1 DIF: Cognitive Level: Comprehension REF: 407 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation 4. A laboring woman received meperidine (Demerol) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate? a. Fentanyl (Sublimaze) c. Naloxone (Narcan) b. Promethazine (Phenergan) d. Nalbuphine (Nubain) ANS: C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl, promethazine, and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Demerol on the neonate. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning, Implementation REF: 409

5. A woman in labor has just received an epidural block. The most important nursing intervention is to: a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia. ANS: C
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The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension. PTS: 1 DIF: Cognitive Level: Application REF: 413 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation 6. The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if: a. The mother gives birth without any analgesic or anesthetic. b. The mother and familys priorities and preferences are incorporated into the plan. c. The primary health care provider decides the best pain relief for the mother and family. d. The nurse informs the family of all alternative methods of pain relief available in the hospital setting. ANS: B The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers, who consult with the woman about their findings and recommendations. The needs of each woman are different, and many factors must be considered before a decision is made whether pharmacologic methods, nonpharmacologic methods, or a combination of the two will be used to manage labor pain. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Planning REF: 416

7. A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: a. Notify the womans physician. b. Tell the woman to slow the pace of her breathing. c. Administer oxygen via a mask or nasal cannula. d. Help her breathe into a paper bag ANS: D This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. This enables her to rebreathe carbon dioxide and replace the bicarbonate ion. PTS: 1 DIF: Cognitive Level: Application REF: 402 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation

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8. A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use: a. Counterpressure against the sacrum. b. Pant-blow (breaths and puffs) breathing techniques. c. Effleurage. d. Conscious relaxation or guided imagery. ANS: A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pantblow, effleurage, and conscious relaxation or guided imagery are usually helpful for contraction per the gate-control theory. PTS: 1 DIF: Cognitive Level: Comprehension REF: 403 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation 9. If an opioid antagonist is administered to a laboring woman, she should be told that: a. Her pain will decrease. b. Her pain will return. c. She will feel less anxious. d. She will no longer feel the urge to push. ANS: B The woman should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist. Opioid antagonists, such as Narcan, promptly reverse the central nervous system (CNS) depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when the opioid is at its peak effect. PTS: 1 DIF: Cognitive Level: Comprehension REF: 408 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning 10. A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the womans intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the womans hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman? a. She is too far dilated. c. She has thrombocytopenia. b. She is anemic. d. She is septic. ANS: C

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The platelet count indicates thrombocytopenia (low platelets), which is a contraindication to epidural analgesia/anesthesia. Typically epidural analgesia/anesthesia is used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the womans hemoglobin and hematocrit are in the normal range and show a slight increase in the WBC count; not uncommon in laboring women. PTS: 1 DIF: Cognitive Level: Analysis REF: 415 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Diagnosis 11. The role of the nurse with regard to informed consent is to: a. Inform the client about the procedure and have her sign the consent form. b. Act as a client advocate and help clarify the procedure and the options. c. Call the physician to see the client. d. Witness the signing of the consent form. ANS: B Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the womans advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician must be present to explain the procedure to the client. However, the nurses responsibilities go further than simply asking the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the states guidelines, the womans husband or another hospital health care employee may sign as witness. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Safe and Effective Care Environment TOP: Nursing Process: Implementation REF: 416

12. A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics often are used with sedatives because: a. The two together work the best for you and your baby. b. Sedatives help the opioid work better, and they also will help relax you and relieve your nausea. c. They work better together so you can sleep until you have the baby. d. This is what the doctor has ordered for you. ANS: B

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Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two drugs to work together more effectively, but it does not ensure maternal or fetal complications. Sedation may be a related effect of some ataractics, but it is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. This is what the doctor has ordered for you may be true, but it is not an acceptable comment for the nurse to make. PTS: 1 DIF: Cognitive Level: Application OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning, Implementation REF: 406

13. To help clients manage discomfort and pain during labor, nurses should be aware that: a. The predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen. b. Referred pain is the extreme discomfort between contractions. c. The somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the second stage. ANS: A This pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 394

14. Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions are experiencing more pain. d. Levels of pain-mitigating -endorphins are higher during a spontaneous, natural childbirth. ANS: D Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension. PTS: 1 DIF: Cognitive Level: Comprehension REF: 396

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Test Bank OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Diagnosis

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15. Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help clients. Nurses should know that _____ women may be stoic until late in labor, when they may become vocal and request pain relief. a. Chinese c. Hispanic b. Arab or Middle Eastern d. African-American ANS: C Hispanic women may be stoic early, more vocal and ready for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start. They may prefer pain medications. African-American women may express pain openly; use of medications for pain is more likely to vary with the individual. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Assessment REF: 396

16. With regard to a pregnant womans anxiety and pain experience, nurses should be aware that: a. Even mild anxiety must be treated. b. Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on. c. Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity. ANS: B Anxiety and pain reinforce each other in a bad cycle. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can build sufficiently to slow the progress of labor. Unfortunately an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Assessment REF: 396

17. Nurses should be aware of the differences experience can make in labor pain such as: a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor. b. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor.

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Test Bank d. Multiparous women have more fatigue from labor and therefore experience more pain.

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ANS: A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue. PTS: 1 DIF: Cognitive Level: Knowledge REF: 397 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Diagnosis 18. In the current practice of childbirth preparation, emphasis is placed on: a. The Dick-Read (natural) childbirth method. b. The Lamaze (psychoprophylactic) method. c. The Bradley (husband-coached) method. d. Getting expectant parents to attend childbirth preparation in any or no specific method. ANS: D Getting expectant parents to class is most important, because preparation increases a womans confidence and thus her ability to cope with labor and birth. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning REF: 398, 399, 401

19. With regard to breathing techniques during labor, maternity nurses should be aware that: a. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. b. By the time labor has begun, it is too late for instruction in breathing and relaxation. c. Controlled breathing techniques are most difficult near the end of the second stage of labor. d. The patterned-paced breathing technique can help prevent hyperventilation. ANS: A First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 402 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation

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20. Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that: a. Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. b. Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. Effleurage is permissible, but counterpressure is almost always counterproductive. d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins. ANS: D Transcutaneous electrical nerve stimulation does help. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks might be more effective than a long soak. Counterpressure can help the woman cope with lower back pain. PTS: 1 DIF: Cognitive Level: Application REF: 403 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning 21. With regard to systemic analgesics administered during labor, nurses should be aware that: a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b. Effects on the fetus and newborn can include decreased alertness and delayed sucking. c. Intramuscular administration (IM) is preferred over intravenous (IV) administration. d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic. ANS: B Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning REF: 407

22. With regard to nerve block analgesia and anesthesia, nurses should be aware that: a. Most local agents are related chemically to cocaine and end in the suffix -caine. b. Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. A pudendal nerve block is designed to relieve the pain from uterine contractions. d. A pudendal nerve block, if done correctly, does not significantly lessen the bearing-down reflex.

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ANS: A Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions and it lessens or shuts down the bearing-down reflex. PTS: 1 DIF: Cognitive Level: Comprehension REF: 409 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning 23. With regard to spinal and epidural (block) anesthesia, nurses should know that: a. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. b. A high incidence of after-birth headache is seen with spinal blocks. c. Epidural blocks allow the woman to move freely. d. Spinal and epidural blocks are never used together. ANS: B Headaches may be prevented or mitigated to some degree by a number of methods. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the womans ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular. PTS: 1 DIF: Cognitive Level: Comprehension REF: 412, 414 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Evaluation 24. A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. This procedure is: a. Not used much anymore. b. Likely to be used in the second stage of labor but not in the first stage. c. An application of nitrous oxide. d. A prelude to cesarean birth. ANS: C This is an application of nitrous oxide, which could be used in either the first or second stage of labor (or both) as part of the preparation for a vaginal birth. PTS: 1 DIF: Cognitive Level: Comprehension REF: 415 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation 25. In assessing a woman for pain and discomfort management during labor, a nurse most likely would: a. Have the woman use a visual analog scale (VAS) to determine her level of pain. b. Note drowsiness as a sign that the medications were working. c. Interpret a womans fist clenching as an indication that she is mad at her male partner and the physician.

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d. Evaluate the womans skin turgor to see whether she needs a gentle oil massage. ANS: A The VAS is a means of adding the womans assessment of her pain to the nurses observations. Drowsiness is a side effect of medications, not usually (sedatives aside) a sign of effectiveness. The fist clenching likely is a sign of apprehension that may need attention. Skin turgor, along with the moistness of the membranes and the concentration of the urine, are signs that help the nurse evaluate hydration. PTS: 1 DIF: Cognitive Level: Application OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 416

26. After change-of-shift report the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: a. Visceral. c. Somatic. b. Referred. d. Afterpain. ANS: B As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning MULTIPLE RESPONSE 1. Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the clients blood pressure? Choose all that apply. a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase intravenous (IV) fluids. d. Administer oxygen. e. Perform a vaginal examination.
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REF: 394

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ANS: B, C, D Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the womans legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. Placing the client in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure. PTS: 1 DIF: Cognitive Level: Comprehension REF: 411 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation COMPLETION 1. Today the pregnant woman has a number of nonpharmacologic measures available to her to assist with pain relief in labor. One such measure involves the application of heat, cold, or pressure to specific areas of the body and is known as ____________________. ANS: Acupressure The effectiveness of acupressure has been attributed to the gate-control theory of pain and an increase in endorphin levels. Pressure is applied to acupuncture points called tsubos. These points have an increased density of neuroreceptors and increased electrical conductivity. Pressure is initially applied with contractions and then continually as labor progresses. PTS: 1 DIF: Cognitive Level: Application REF: 403, 404 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation

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