A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit.

Complete the following sentence by using the list of options.
The nurse should identify that

____________

and

___________

are findings that require follow-up.

Choice A rationale

Fetal heart rate assessment is paramount before administering an opioid analgesic during labor. Opioids can cross the placental barrier and cause central nervous system depression in the fetus, potentially leading to decreased fetal heart rate variability or transient decelerations. Therefore, a baseline and ongoing fetal heart rate monitoring is essential to ensure fetal well-being.

Choice B rationale

Deep tendon reflexes are primarily assessed when administering magnesium sulfate for preeclampsia, not typically before opioid analgesics. Magnesium sulfate can cause central nervous system depression and affect neuromuscular transmission, necessitating regular monitoring of deep tendon reflexes to assess for signs of toxicity. Opioids do not directly affect reflex activity in the same manner.

Choice C rationale

Blood glucose levels are not a standard assessment before administering opioid analgesics during labor. Blood glucose monitoring is crucial for clients with diabetes or gestational diabetes, or those receiving intravenous dextrose, but it is not directly related to opioid administration and its immediate effects on the mother or fetus.

Choice D rationale

Blood pressure assessment is crucial before administering an opioid analgesic because these medications can cause maternal hypotension due to their vasodilatory effects. Hypotension can reduce placental perfusion, compromising fetal oxygenation. Establishing a baseline blood pressure and monitoring it closely after administration helps ensure maternal cardiovascular stability and fetal well-being.

Choice E rationale

Pain level assessment is fundamental before administering an opioid analgesic. The primary purpose of administering an opioid is to alleviate labor pain. A thorough assessment of the intensity, location, and character of pain guides the choice, dosage, and timing of the analgesic, ensuring effective pain management and patient comfort while minimizing unnecessary medication.

Choice A rationale

Encouraging the client to listen to music is an effective non-pharmacological pain management strategy in the latent phase of labor. Music provides a distraction, promotes relaxation, and can help to reduce the perception of pain by stimulating the release of endorphins, fostering a calmer environment and coping mechanism.

Choice B rationale

Instructing the client on biofeedback is a complex technique that requires training and practice for effective use. While it can be beneficial, the latent phase of labor may not be the ideal time to introduce and teach a new skill like biofeedback, as the client's focus may be limited by contractions and discomfort.

Choice C rationale

Administering fentanyl 100 mcg every hour via intermittent intravenous bolus is a pharmacological intervention typically used for more intense pain in active labor or for clients who desire or require stronger pain relief. The latent phase is characterized by milder, less frequent contractions, making non-pharmacological methods or lower-dose analgesics more appropriate.

Choice D rationale

Requesting a pudendal nerve block is usually reserved for the second stage of labor, specifically for episiotomy repair or forceps delivery, rather than for pain management during the latent phase. It provides regional anesthesia to the perineum and lower vagina, not generalized pain relief for uterine contractions in early labor.