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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

A shrill cry may indicate distress but isn't specifically related to hypoglycemia in newborns.

Choice B rationale

Weak peripheral pulses are more commonly associated with circulatory or cardiac issues rather than hypoglycemia.

Choice C rationale

Yellowish skin suggests jaundice, which is due to elevated bilirubin levels, not hypoglycemia.

Choice D rationale

Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns, indicating a need to check blood glucose levels.

Correct Answer is C

Explanation

Choice A rationale

Feeding from only one breast can lead to engorgement and a decrease in milk supply in the affected breast. It is important to continue breastfeeding from both breasts, even if one is infected.

Choice B rationale

Discarding milk is not necessary and can lead to a decrease in milk supply. The infection does not harm the baby, and breastfeeding helps to drain the breast and clear the infection.

Choice C rationale

Moist heat can help to increase blood flow and promote healing in the affected breast. Applying warm compresses or taking warm showers can help to reduce pain and inflammation associated with mastitis.

Choice D rationale

While staying hydrated is important for overall health, there is no specific requirement to drink at least 1500 milliliters of fluid per day for mastitis. Adequate fluid intake should be maintained, but there is no direct correlation with resolving the infection.

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