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 D
Explanation
Choice A rationale
Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.
Choice B rationale
A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.
Choice C rationale
Late decelerations are concerning and not expected as they may indicate fetal distress.
Choice D rationale
Contractions lasting about 75 seconds are expected during the active phase of labor.
Correct Answer is B
Explanation
Choice A rationale
During labor, the body experiences physiological stress, which typically causes an increase, not a decrease, in white blood cell (WBC) count. This increase is a normal response to stress.
Choice B rationale
Blood glucose levels can decrease during labor due to the energy expenditure and physiological demands of the process. This is why it is important to monitor glucose levels and provide necessary interventions if hypoglycemia occurs.
Choice C rationale
The respiratory rate generally increases during labor to meet the increased oxygen demands of the body. A decrease in respiratory rate is not expected during this time.
Choice D rationale
Body temperature may increase slightly during labor due to the physical exertion and metabolic activity involved. A decrease in temperature is not a typical finding during labor.