A nurse is caring for a client who is in labor, just received spinal anesthesia, and is experiencing hypotension. Which of the following actions should the nurse take?

A. Severe abdominal pain: Severe abdominal pain is more commonly associated with placental abruption, not placenta previa. In placenta previa, the placenta covers the cervical opening, which typically causes painless bleeding rather than significant abdominal discomfort.

B. Delayed menses: Delayed menses is not related to placenta previa. This condition occurs during pregnancy, after menses have already ceased, and does not influence menstrual timing.

C. Nausea: Nausea is a common symptom in early pregnancy due to hormonal changes but is not a characteristic finding of placenta previa. It does not help in diagnosing or identifying this placental complication.

D. Spotting: Spotting or painless vaginal bleeding, especially in the second or third trimester, is a hallmark sign of placenta previa. The bleeding occurs because the placenta partially or completely covers the cervical os, and it often requires careful monitoring and management to prevent maternal and fetal complications.

A. Administer a dose of fluoxetine to the client: Fluoxetine is an antidepressant and is not indicated for acute psychotic symptoms such as auditory hallucinations in schizophrenia. Antipsychotic medications, not SSRIs, are the standard treatment for managing hallucinations.

B. Avoid making eye contact with the client: Avoiding eye contact can be perceived as disengagement or disinterest, which may increase the client’s anxiety or mistrust. Therapeutic communication with appropriate eye contact helps establish rapport and conveys presence and support.

C. Request the client to lie down in a quiet room: Forcing the client to lie down may increase distress or feelings of loss of control. While a quiet environment can reduce stimuli, the intervention should be voluntary and focused on coping strategies rather than directives.

D. Encourage the client to listen to music: Listening to music can help distract the client from hallucinations and provide a coping mechanism to reduce distress. This intervention supports safety, comfort, and engagement without confrontation, aligning with therapeutic approaches for managing auditory hallucinations.