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?

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.

The nurse should identify that weeks of gestation and contraction pattern are findings that require follow-up.

Rationale for correct answers:
Weeks of gestation at 32 weeks indicate a preterm pregnancy (<37 weeks), making any contractions concerning for possible preterm labor. The contraction pattern of increasing frequency (from every 5 minutes to every 3 minutes), longer duration (30 to 60 seconds), and moderate intensity signifies active uterine activity that can precipitate cervical changes and preterm birth risk. These two parameters warrant close monitoring and intervention to prevent premature delivery.

Rationale for incorrect answers (Response 1 options):
Blood pressure is within normal limits (128/83 and 117/80 mm Hg), so hypertensive disorders like preeclampsia are not indicated here. Pain score remains low (2/10), which is mild and not a primary indicator for urgent intervention. Parity (G1P0) does not influence immediate risk assessment for this clinical presentation.

Rationale for incorrect answers (Response 2 options):
Fetal heart rate remains normal at 140/min with no decelerations, indicating fetal well-being at this time. Nitrazine test is negative, showing intact membranes, which reduces the risk of premature rupture of membranes. Temperature is normal at 37°C, ruling out infection as a cause of contractions. Therefore, these findings do not require urgent follow-up in this scenario.