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A nurse is caring for a client who is in the first stage of labor. The client is stating that her pain level is 8/10 during her contractions but does not want an epidural. The nurse assists with a position change and offers Fentanyl for pain relief. The client requests the offered pain medication. What action should the nurse perform first?

A.

Provide ice chips or mouth swabs.

B.

Assess and document maternal vital signs and fetal heart rate after medication.

C.

Dim the lights and provide a quiet atmosphere.

D.

Assist the patient with coping skills including breathing techniques.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Providing ice chips or mouth swabs can help keep the client comfortable and hydrated, but it is not the priority action when administering pain medication.

 

Choice B rationale

 

Assessing and documenting maternal vital signs and fetal heart rate after administering Fentanyl is crucial. This ensures that the medication is not causing any adverse effects on the mother or fetus and that both are stable.

 

Choice C rationale

 

Dimming the lights and providing a quiet atmosphere can help create a calming environment, but it is not the priority action when administering pain medication.

 

Choice D rationale

 

Assisting the patient with coping skills, including breathing techniques, is important for managing pain, but it is not the priority action when administering pain medication.


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Correct Answer is A

Explanation

Choice A rationale

The “Passenger” refers to the fetus and its position, size, and presentation. In this case, the fetus has an estimated weight of 9 lbs and is in the left occiput posterior (LOP) position. These factors can complicate labor by making it more difficult for the fetus to navigate through the birth canal, potentially leading to prolonged labor and increased risk of interventions.

Choice B rationale

The “Passage” refers to the birth canal, including the pelvis and soft tissues. While the passage is an important factor in labor, the primary concern in this scenario is the size and position of the fetus, which falls under the “Passenger” category.

Choice C rationale

The “Powers” refer to the strength and frequency of uterine contractions. Although the patient is having contractions every 3 minutes, the main concern here is the fetal size and position, which are more directly related to the "Passenger"4.

Choice D rationale

The “Psyche” refers to the psychological state of the mother, including her stress levels and emotional well-being. While important, the primary concern in this scenario is the physical factors related to the fetus, which are categorized under the "Passenger"4.

Correct Answer is A

Explanation

Choice A rationale

The occiput anterior (OA) position is considered the optimal fetal position for vaginal birth. In this position, the baby’s head is down, and the back of the head (occiput) is facing the mother’s front. This position allows for the most efficient passage through the birth canal.

Choice B rationale

The occiput posterior (OP) position, where the baby’s head is down but facing the mother’s back, can lead to a longer and more painful labor. It is not considered optimal for vaginal birth.

Choice C rationale

Breech positions, where the baby’s buttocks or feet are positioned to come out first, are not optimal for vaginal birth and often require a cesarean section due to the increased risk of complications.

Choice D rationale

The transverse position, where the baby is lying sideways across the uterus, is not suitable for vaginal birth. This position typically requires a cesarean section to safely deliver the baby.

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