Difficulty: Medium
Average Score: 91%
Simulated
Passage / Scenario
A nurse is caring for a client who is in the first stage of labor. The client is stating that her pain level is 8/10 during her contractions but does not want an epidural. The nurse assists with a position change and offers Fentanyl for pain relief. The client requests the offered pain medication.What action should the nurse perform first?
Correct answer
B
Rationale
Assessing and documenting maternal vital signs and fetal heart rate after administering Fentanyl ensures no adverse effects on the mother or fetus, making it the priority.