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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Elevated BUN levels (25 mg/dL) can indicate kidney dysfunction, dehydration, or high protein intake. However, it’s not directly related to a prenatal complication, though it still
requires monitoring.
Choice B rationale
Hemoglobin (Hgb) of 10.2 mg/dL is below the normal range (11 to 16 mg/dL) and can indicate anemia. During pregnancy, anemia can lead to serious complications such as preterm
birth and low birth weight, making this result significant.
Choice C rationale
A fasting blood glucose level of 70 mg/dL falls within the normal range (70 to 110 mg/dL) and does not indicate a complication. Thus, it is not concerning in the context of prenatal
complications.
Choice D rationale
Hematocrit (Hct) of 32% is slightly below the normal range (33 to 47%), which can be common in pregnancy due to increased plasma volume. While monitoring is required, it’s not as
critical as anemia.
Correct Answer is D
Explanation
Choice A rationale
Instituting droplet precautions is not necessary for herpes simplex virus (HSV). HSV is primarily transmitted through direct contact with infected body fluids or lesions, not through respiratory droplets.
Choice B rationale
Administering ceftriaxone sodium is not appropriate for HSV. Ceftriaxone is an antibiotic used to treat bacterial infections, whereas HSV is a viral infection and requires antiviral treatment.
Choice C rationale
Informing the client they should bottlefeed the newborn is not necessary. Mothers with HSV can breastfeed as long as there are no herpetic lesions on the breast. Proper hand hygiene and preventive measures should be taken to avoid transmission.
Choice D rationale
Obtaining surface cultures from the newborn is the appropriate action. This helps in detecting the presence of HSV and initiating antiviral treatment if necessary. Early detection and treatment are crucial in preventing severe complications associated with neonatal HSV infection.