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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 A

Explanation

Choice A rationale

Irregular heartbeat (palpitations or arrhythmias) can indicate a serious cardiovascular side effect of nifedipine. It requires immediate medical attention as it could compromise

maternal and fetal circulation.

Choice B rationale

Hair loss is not a known adverse effect of nifedipine and generally does not pose a significant health risk. It is more commonly associated with hormonal changes rather than

medication side effects.

Choice C rationale

Increased salivation is not a common side effect of nifedipine. Nifedipine primarily affects the cardiovascular system rather than salivary glands.

Choice D rationale

Pause is not a recognized adverse effect related to nifedipine usage. The term itself is ambiguous and not typically associated with the pharmacological profile of nifedipine.

Correct Answer is ["B","C","D","E","F"]

Explanation

A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.

B. "You may experience a headache after receiving this medication."
Some tocolytic medications can cause headaches as a side effect.


C. "It is common for this medication to make you feel jittery."
Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.

D. "This medication should decrease your contractions."
The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.


E. "I'll check your reflexes frequently while you are receiving this medication."
Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.


F. "This medication can make your heart beat faster."
Tocolytic medications, such as terbutaline, can increase heart rate.


G. "This medication can increase your blood pressure.":

Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.

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