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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 D

Explanation

Choice A rationale

Leukorrhea is a common and normal occurrence in pregnancy due to increased estrogen production and greater blood flow to the vaginal area. It is usually a thin, white discharge and not a cause for concern unless accompanied by itching, burning, or an unusual odor.

Choice B rationale

Excessive salivation, also known as ptyalism, can occur during pregnancy, particularly in the first trimester. It is linked to hormonal changes and is not typically harmful, though it may be uncomfortable for the patient.

Choice C rationale

Darkening of the skin on the face, known as melasma or chloasma, is common during pregnancy and is due to increased pigmentation from hormonal changes. It typically resolves postpartum and is not harmful.

Choice D rationale

Epigastric pain in a pregnant client at 33 weeks gestation can be a sign of preeclampsia, a serious condition characterized by high blood pressure and damage to other organs. It requires immediate medical attention to prevent complications for both the mother and baby.

Correct Answer is C

Explanation

Choice A rationale

Patterned breathing techniques can help in managing pain by focusing on controlled breathing, reducing anxiety, and providing a distraction from the pain, but are not specifically targeting back labor pains.

Choice B rationale

Effleurage involves light circular strokes on the abdomen and can help in managing general labor pain, but may not be as effective specifically for back labor pains.

Choice C rationale

Sacral counterpressure involves applying steady pressure to the sacral area, which can help relieve pain caused by back labor by counteracting the discomfort experienced in this

area.

Choice D rationale

Guided imagery involves using mental visualization to distract from pain and promote relaxation, but may not be as effective in relieving the specific pain associated with back labor.

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