A nurse is caring for a client who is 42 weeks of gestation.

Exhibits

Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated

The correct answer is A. Slow-paced breathing

A. Slow-paced breathing is a nonpharmacological comfort measure that involves taking slow, deep breaths to promote relaxation and reduce anxiety. It can be an effective technique for managing pain during contractions.

B. Biofeedback involves the use of electronic monitoring to provide feedback about physiological processes, and it is not typically used as a primary nonpharmacological comfort measure for labor pain.

C. Self-hypnosis is a relaxation technique that involves guided imagery and focused concentration to promote relaxation and reduce pain. However, it may require some previous knowledge or practice, and in the context of this scenario, slow-paced breathing may be a more immediate and accessible option.

D. Acupuncture involves the insertion of needles into specific points on the body to stimulate energy flow. While acupuncture can be effective for pain management, it may not be readily available in all labor settings, and slow-paced breathing is a more universally applicable option.

Choice A Reason:

Placing the client in a supine position for 30 minutes following the first dose of anesthetic solution is not a standard recommendation. The positioning during epidural placement is typically a seated or side-lying position.

Choice B Reason:

Administering 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution is not a standard practice for epidural anesthesi

A. Fluids may be administered, but the type and volume depend on the patient's individual needs and the healthcare provider's orders.

Choice C Reason:

Monitoring the client's blood pressure every minute following the first dose of anesthetic solution is appropriate. Epidural anesthesia can potentially cause hypotension (low blood pressure), which is a common side effect. Therefore, close monitoring of the client's blood pressure is crucial, especially following the administration of the initial dose of the anesthetic solution. The goal is to promptly detect and manage any decrease in blood pressure to ensure the well-being of both the mother and the baby.

Choice D Reason:

Ensuring the client has been NPO (nothing by mouth) for 4 hours prior to the placement of the epidural and the first dose of anesthetic solution is not a specific requirement for epidural anesthesi

A. NPO status is more relevant to surgical procedures involving general anesthesia and is not typically a strict requirement for epidural placement.