The nurse receives orders for pharmacologic pain relief. What does the nurse explain to the laboring person after administering fentanyl?

Correct Answer: A

Rationale: Rationale: After administering fentanyl, the nurse explains the need to monitor oxygen saturation due to the potential respiratory depression as a side effect of the medication. This is crucial for early detection and intervention. Monitoring for vaginal bleeding (C) is unrelated to fentanyl administration. Inserting a Foley catheter (B) and checking the cervix (D) are not necessary post-fentanyl administration. Oxygen saturation monitoring is the priority for patient safety.

Correct Answer: A

Rationale: The correct answer is A: monitoring vital signs every 5 to 15 minutes. After inserting the epidural catheter, continuous monitoring of vital signs is crucial to detect any potential complications like hypotension or respiratory depression promptly. Vital signs include blood pressure, heart rate, respiratory rate, and oxygen saturation. Intermittent FHR monitoring (B) may be necessary but is not the primary responsibility after epidural insertion. Providing a meal (C) is contraindicated due to the risk of aspiration. Instructing the laboring person to get out of bed to use the restroom (D) is not recommended as they may be at risk of falls due to decreased sensation and muscle weakness from the epidural.

Correct Answer: D

Rationale: The correct answer is D: pain during injection. Local anesthesia may cause pain during injection due to the needle piercing the skin, which can be uncomfortable for the patient. This is a common disadvantage of local anesthesia. A: Decreased motor function is not a typical disadvantage of local anesthesia as it mainly affects sensory nerves rather than motor nerves. B: Nausea is not a direct side effect of local anesthesia as it does not affect the gastrointestinal system. C: Hypotension is not a common disadvantage of local anesthesia, as it typically does not have a significant impact on blood pressure unless administered in large amounts or combined with other medications that can lower blood pressure.

Correct Answer: C

Rationale: The correct answer is C: During the increment of the next contraction. This is the best time for assessment as the patient is likely to be more focused and cooperative during this phase. Asking questions or performing procedures during the contraction or immediately after may be distracting or uncomfortable for the patient. Waiting until the contraction is over (choice A) may delay necessary assessment. Waiting for the coach's approval (choice B) may not always align with the patient's needs. Waiting until after administration of analgesic-anesthetic (choice D) may not be timely for necessary assessment and may also impact the patient's ability to provide accurate information.

Correct Answer: C

Rationale: The correct answer is C because nonpharmacologic pain management methods, such as relaxation techniques or massage, do not involve medications that could potentially harm the fetus. This ensures there are no side effects or risks to the fetus during labor. Option A is incorrect as nonpharmacologic pain management does not necessarily guarantee a more rapid labor. Option B is incorrect because while nonpharmacologic methods can provide pain relief, it may not always be more complete compared to pharmacologic options. Option D is incorrect as some nonpharmacologic methods may alter alertness levels, such as hypnosis.