A woman in active labor is experiencing intense pain and requests non-pharmacological pain relief measures. What intervention should the nurse prioritize?

Correct Answer: A

Rationale: When a woman in active labor is experiencing intense pain and requests non-pharmacological pain relief measures, the nurse should prioritize providing continuous labor support. Continuous labor support, also known as a doula or labor companion, has been shown to be effective in reducing the perception of pain and improving labor outcomes. The presence of a supportive person can provide physical, emotional, and informational support, helping the woman cope with the pain and navigate through the labor process. This intervention can enhance the woman's overall experience of labor and improve maternal and neonatal outcomes without the need for pharmacological interventions. Administering opioids, performing epidural analgesia, or initiating nitrous oxide inhalation are pharmacological pain relief measures and may not align with the woman's preference for non-pharmacological options.

Correct Answer: A

Rationale: An occiput posterior fetal position, where the baby's head is facing the mother's abdomen rather than her back, can lead to prolonged and severe back pain during labor. This position can cause irregular contractions and difficulty in descending through the birth canal, resulting in abnormal labor progress. The back pain experienced in this case is often intense due to the pressure exerted on the mother's lower back and may also be associated with intense back labor. It is essential for the nurse to recognize this potential issue and assist in maneuvers or positions to help the baby rotate to a more optimal position for delivery.

Correct Answer: A

Rationale: Placing the mother in a hands-and-knees position can help facilitate fetal rotation from occiput posterior to the desired occiput anterior position. This position utilizes gravity to assist in the repositioning of the baby, ultimately helping to alleviate back pain and promoting more efficient labor progress. It allows the baby's head to descend properly into the pelvis, potentially reducing the risk of a prolonged labor or the need for instrumental delivery. Additionally, being in this position can help the mother feel more comfortable and empowered during labor. Overall, assisting the mother into a hands-and-knees position is a non-invasive, low-risk intervention that can have a positive impact on both the mother and baby's well-being during labor.

Correct Answer: B

Rationale: Administering ice packs to the perineum is the priority nursing intervention to provide relief for perineal pain and discomfort in a postpartum client. Ice packs help to reduce swelling and inflammation in the perineal area, which can help alleviate pain. It is a safe and effective method to provide immediate relief and promote comfort for the client. Other interventions such as encouraging ambulation, administering analgesics, and recommending warm sitz baths can also be beneficial, but in the initial management of perineal pain, ice packs are the most appropriate choice.

Correct Answer: A

Rationale: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.