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A nurse is developing a plan of care for a client who is in the latent phase of labor.
Which of the following interventions should the nurse include in the plan to manage the client's pain?

A.

Encourage the client to listen to music.

B.

Instruct the client on how to use biofeedback.

C.

Administer fentanyl 100 mg every hour via intermittent bolus.

D.

Request the provider to administer a pudendal nerve block.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Music can be a non-pharmacological method to help manage pain and anxiety during the latent phase of labor.

 

Choice B rationale

Biofeedback might be helpful but can be challenging to implement without prior training.

 

Choice C rationale

Administering fentanyl 100 mg every hour is not appropriate; fentanyl is typically administered in much smaller doses.

 

Choice D rationale

A pudendal nerve block is usually reserved for the second stage of labor or delivery, not the latent phase.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Monitoring blood pressure every 30 minutes following epidural placement is important but not the initial action. Epidural anesthesia can lead to a sudden drop in blood pressure, so

frequent monitoring is crucial. However, the initial step should focus on preventing hypotension.

Choice B rationale

Administering lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement helps in maintaining blood pressure. Epidural anesthesia can cause vasodilation,

leading to hypotension. Preloading with fluids ensures adequate blood volume and reduces the risk of a significant drop in blood pressure.

Choice C rationale

Administering oxygen via nasal cannula at 2 L/min prior to epidural placement is not necessary unless the client has respiratory complications. Oxygen supplementation is used to

treat or prevent hypoxia, which is not a primary concern in this scenario.

Choice D rationale

Repositioning the client every hour following epidural placement is important to ensure even distribution of the anesthetic and prevent pressure sores. However, this is not the initial

action to take for preventing hypotension.

Correct Answer is B

Explanation

Choice A rationale

Meconium stools are common in newborns and not a concern in the context of weight loss.

Choice B rationale

Depressed fontanels can indicate dehydration in a newborn, which is critical, especially with significant weight loss.

Choice C rationale

Rust-stained urine is often due to urate crystals and is typical in newborns, not specifically alarming.

Choice D rationale

Overlapping suture lines can be a normal finding in a newborn's head and not indicative of an acute problem relating to weight loss.

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