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

The human body possesses compensatory mechanisms, such as sympathetic nervous system activation leading to vasoconstriction and increased heart rate, that can maintain vital organ perfusion despite significant blood loss. These mechanisms can mask overt signs of shock, such as hypotension, until approximately 20-25% of the total blood volume (around 1000-1250 mL in an average adult) has been acutely lost. This delay in visible manifestations can be critical in situations like postpartum hemorrhage, where rapid blood loss can occur.

Choice B rationale

Hemorrhagic shock typically leads to a state of metabolic acidosis, not an increase in serum pH. This occurs due to inadequate tissue perfusion, resulting in anaerobic metabolism and the accumulation of lactic acid. The reduced oxygen delivery forces cells to switch from efficient aerobic respiration to less efficient anaerobic glycolysis, producing lactate as a byproduct, which lowers the blood pH. A normal serum pH range is 7.35 to 7.45.

Choice C rationale

While urine output is a valuable indicator of renal perfusion and overall circulatory status, it is not the most accurate or immediate indicator of *overall* organ perfusion. Other parameters like mental status, skin perfusion (capillary refill), and arterial blood pressure (MAP) provide more global and rapid assessments of tissue oxygenation. Urine output primarily reflects renal blood flow, which can be maintained by compensatory mechanisms even when other organs are hypoperfused. Normal urine output is generally considered to be 0.5 to 1 mL/kg/hr.

Choice D rationale

The standard resuscitation guideline for hemorrhagic shock is to administer 3 mL of isotonic crystalloid solution, such as lactated Ringer's, for every 1 mL of estimated blood loss. This 3: ratio accounts for the rapid redistribution of crystalloids from the intravascular space to the interstitial space, meaning that only about one-third remains within the vascular compartment to expand circulating blood volume effectively.

Choice A rationale

Prior to IUD insertion, screening for sexually transmitted infections (STIs) is crucial to prevent the introduction of pathogens into the upper reproductive tract. An untreated STI, particularly chlamydia or gonorrhea, can lead to pelvic inflammatory disease (PID) when an IUD is placed, as the device might facilitate the ascent of bacteria.

Choice B rationale

The duration of effectiveness for intrauterine devices varies depending on the type. Hormonal IUDs typically last for 3 to 8 years, while copper IUDs can remain effective for up to 10 years. Therefore, the statement that the device must be replaced every 2 years is incorrect and misleading for most available IUDs.

Choice C rationale

Irregular spotting and changes in menstrual bleeding patterns are common side effects during the initial months following IUD placement, particularly with hormonal IUDs. This is due to the local endometrial effects of progesterone release or the inflammatory reaction induced by copper, as the uterus adapts to the foreign body.

Choice D rationale

There is no medical contraindication to using tampons with an IUD. The IUD resides in the uterus, while tampons are inserted into the vaginal canal. There is no physical interaction or risk of dislodgement of the IUD by tampon use. Clients can continue their preferred menstrual hygiene products.

Choice E rationale

Informed consent is a fundamental ethical and legal requirement before any medical procedure, including IUD insertion. The client must be provided with comprehensive information regarding the procedure, including its benefits, risks, alternatives, and potential side effects, to make an autonomous and voluntary decision.