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?
Encourage the client to listen to music.
Instruct the client on how to use biofeedback.
Administer fentanyl 100 mg every hour via intermittent bolus.
Request the provider to administer a pudendal nerve block.
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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Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Hypertension is not a characteristic finding of hyperemesis gravidarum, which primarily affects fluid balance and nutritional status.
Choice B rationale
Dry mucous membranes are a sign of dehydration, commonly associated with hyperemesis gravidarum due to excessive vomiting.
Choice C rationale
Tachycardia can result from dehydration and electrolyte imbalances seen in hyperemesis gravidarum.
Choice D rationale
Poor skin turgor indicates dehydration, a common symptom of hyperemesis gravidarum.
Choice E rationale
Polyuria is not typical in hyperemesis gravidarum; the condition usually leads to dehydration, reducing urine output.
Correct Answer is C
Explanation
Choice A rationale
Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.
Choice B rationale
Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.
Choice C rationale
Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.
Choice D rationale
Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.