The nurse is caring for a primigravida at 36-weeks gestation admitted with suspected partial placental abruption. What actions will the nurse implement? Select all that apply.

Choice A reason: Waiting until the urge to push before going to the hospital is not advisable. If the water has broken, it indicates that Labor may be starting, and the pregnant person should be evaluated to ensure the safety of both the parent and the baby.

Choice B reason: Waiting for contractions to start before calling back is not recommended. If the water has broken, there is a risk of infection and other complications, so immediate evaluation is necessary.

Choice C reason: Coming to the Labor and delivery unit for an evaluation is the correct response. When the water breaks, it is important to assess the mother and baby to determine the next steps and ensure that both are healthy and safe.

Choice D reason: Drinking water and lying down is not an appropriate response to the water breaking. While staying hydrated is important during pregnancy, the priority should be to seek immediate medical evaluation.

Choice A reason: Calling the healthcare provider is a valid action if the nurse encounters an unexpected issue or an emergency. However, in this situation, the nurse's immediate observation of physical signs indicating pain suggests that the patient might be experiencing discomfort. The nurse has enough clinical judgment to address the pain directly rather than waiting for a healthcare provider's intervention, which could delay relief.

Choice B reason: Waiting for the patient to report pain is not an ideal choice here because children, especially younger ones, may not always verbalize their pain even when they are in discomfort. The nurse's role involves assessing both verbal and non-verbal cues to provide timely and appropriate care. Physical signs such as clenched fists and a wrinkled forehead strongly indicate pain, necessitating prompt action rather than waiting.

Choice C reason: Administering intravenous morphine is the appropriate intervention given the clear physical signs of pain observed by the nurse. Morphine is a powerful opioid analgesic used to manage moderate to severe pain. In a post-surgical context, controlling pain effectively is crucial for the patient's recovery. Therefore, this action aligns with the need for timely pain management to ensure the child's comfort and facilitate healing.

Choice D reason: Instructing the parent to play relaxing music can be a helpful non-pharmacological intervention to provide a calming environment for the child. However, this action alone is unlikely to address the acute pain suggested by the patient's physical signs. While it can be part of a comprehensive pain management plan, the primary approach should be administering medication to relieve the immediate pain.