A nurse is caring for a woman who is in active labor and wants to use water immersion as a nonpharmacologic pain management method.
What should the nurse do before assisting the woman into the tub?
A Check the fetal heart rate and position.
B Administer a dose of IV analgesia.
C Obtain a written consent from the woman.
D Measure the temperature and depth of the water.
The Correct Answer and Explanation is:
The correct answer is D: Measure the temperature and depth of the water.
Before assisting a woman in active labor into a tub for water immersion, it is crucial for the nurse to ensure that the water is at a safe and comfortable temperature, as well as at an appropriate depth. Water immersion can be an effective nonpharmacologic pain management technique that helps to relax the woman and reduce the perception of pain during labor. However, there are several considerations the nurse must take into account to ensure safety and comfort.
First, the temperature of the water should be carefully monitored. The recommended temperature for laboring in water is typically between 96°F to 100°F (approximately 36°C to 38°C). Water that is too hot can lead to maternal overheating, dehydration, and can stress the fetus. On the other hand, water that is too cold may not provide the soothing effects the woman is seeking and can also contribute to discomfort.
Next, the depth of the water is important to ensure that the woman can be fully immersed without risking safety. The water should be deep enough to allow for effective immersion, covering at least the lower abdomen, but not so deep that it becomes difficult for the woman to move or for the nurse to assist her if needed.
While checking the fetal heart rate and position (option A) is essential during labor, it can be done before or after assessing the water, as it does not directly relate to the immediate safety of water immersion. Administering IV analgesia (option B) would not be appropriate as the woman has expressed a desire for nonpharmacologic pain management. Obtaining written consent (option C) is also important but may not be necessary in every setting, especially if the woman has previously expressed her wishes to utilize water immersion as part of her birth plan.
In summary, the most immediate and relevant action for the nurse is to ensure the water’s temperature and depth are appropriate for the woman’s safety and comfort before she enters the tub.