A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?

The correct answer is A.

A. Determine respiratory function: The priority is to assess the client's airway, breathing, and circulation (ABCs). If the client becomes unresponsive, the nurse should quickly assess whether the airway is clear, check for breathing, and determine if there is a pulse. This initial assessment is crucial for identifying and addressing any immediate life-threatening issues.

B. Increase the TV fluid rate: While fluid administration may be necessary in certain situations, it is not the first priority when a client becomes unresponsive. Assessing respiratory function and circulation takes precedence to address immediate life-threatening concerns.

C. Access emergency medications from the cart: Accessing emergency medications may be necessary, but it should occur after the initial assessment of the client's airway, breathing, and circulation. Administering medications without first assessing the client's ABCs may delay appropriate interventions.

D. Collect a maternal blood sample for coagulopathy studies: This action is important for assessing coagulation status, but it is not the first priority when a client becomes unresponsive. The immediate focus should be on ensuring the client has a patent airway, is breathing, and has a pulse.

Choice A Reason:

Cholecystitis is correct. Both estrogen and progesterone have been shown to increase the risk of gallstones.Estrogen has been shown to increase cholesterol production in the liver, with excess amounts precipitating in bile and leading to the formation of gallstones.Progesterone has been shown to decrease gall-bladder motility, which impedes bile flow and leads to gallstone formation.

Choice B Reason:

Hypertension is correct. Women with uncontrolled hypertension or severe hypertension are generally advised against using oral contraceptives due to the increased risk of cardiovascular events.

Choice C Reason:

Human papillomavirus (HPV) is incorrect. HPV is not a contraindication to oral contraceptives.Overall, while there may be some association between oral contraceptive use and HPV infection or its progression, the absolute increase in risk is generally considered small, and the benefits of oral contraceptives in preventing unintended pregnancies and managing menstrual issues often outweigh the potential risks.

Choice D Reason:

Migraine headaches is correct. Women with migraines with aura, especially those over 35 years old, are often advised against using estrogen-containing contraceptives due to an increased risk of stroke.

Choice E Reason:

Anxiety disorder is incorrect. Anxiety disorder alone is not a contraindication to oral contraceptives. However, individual health considerations should be discussed with a healthcare provider.