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
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.
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