A client who is 39 weeks gestation calls the labor and delivery unit to report that she is experiencing mild, irregular contractions. She tells the practical nurse (PN) that the healthcare provider examined her in the clinic today, and her cervix was 3 cm dilated, with intact membranes, and the presenting part was at -1 station. Which intervention should the PN implement?

The correct answer is choiceB. Verify completion of all new prescriptions. This task is crucial to ensure patient safety and proper medication administration.

Choice A rationale:

Clean up and organize the nurses’ workstation: While maintaining an organized workstation is important for efficiency and reducing stress, it is not the highest priority task. Patient safety and care tasks take precedence over organizational tasks.

Choice B rationale:

Verify completion of all new prescriptions: This is the highest priority because verifying new prescriptions ensures that patients receive the correct medications as prescribed by their healthcare providers.This step is critical to prevent medication errors, which can have serious or even fatal consequences. Ensuring the accuracy of medication orders directly impacts patient safety and care quality.

Choice C rationale:

Calculate and record intake and output totals: Monitoring and recording intake and output is important for assessing a patient’s fluid balance and overall health status. However, this task can be delegated to another team member and does not take precedence over verifying medication orders, which is more time-sensitive and directly related to patient safety.

Choice D rationale:

Write a narrative shift summary for each client: Documenting a shift summary is essential for continuity of care and communication between healthcare providers. However, this task can be completed after ensuring that all critical patient care tasks, such as verifying new prescriptions, are addressed first.

The correct answer is choice D. Apply a pain scale to describe intensity.

Choice A rationale:

Asking about elements of the pain experience is important for a comprehensive pain assessment, but it is not the most critical aspect immediately after administering an analgesic. This step is more relevant during the initial assessment to understand the nature and characteristics of the pain.

Choice B rationale:

Questioning the client about precipitating factors can help identify what triggers the pain, which is useful for long-term pain management strategies. However, this is not the primary focus after giving an analgesic, as the immediate goal is to evaluate the effectiveness of the pain relief.

Choice C rationale:

Locating where in the body the pain occurs is essential for diagnosing and understanding the pain’s origin. However, after administering an analgesic, the priority is to assess the change in pain intensity rather than its location.

Choice D rationale:

Applying a pain scale to describe intensity is crucial after giving an analgesic because it provides a quantifiable measure of the pain relief achieved. This helps in determining the effectiveness of the medication and guides further pain management interventions.

By focusing on the pain intensity using a standardized pain scale, the practical nurse can objectively evaluate the patient’s response to the analgesic and make informed decisions about any additional pain management needs.