Heather, a postpartum woman who experienced a spontaneous vaginal birth 12 hours ago, describes a headache that is worsening
Heather was given two regular strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. Several friends and family members are presently visiting Heather. The nurse notes that Heather's pain relief during labor consisted of a single dose of an IM narcotic. The most appropriate nursing action at this time is to:
a. Notify Heather's health-care provider about Heather's headache.
b. Dim the lights in Heather's room so that she is able to get some rest.
c. Ask Heather's visitors to leave now to decrease Heather's environmental stimuli.
d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain.
ANS: d
The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort in order to provide interventions in a timely manner and enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale.
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