A client in labor who rates pain as 9 on a scale from 1 to 10 requests pain medication after refusing epidural anesthesia. What action should the nurse take prior to administering butorphanol tartrate (Stadol) as prescribed?
1. Offer epidural anesthesia again.
2. Administer oxygen via face mask at 6 to 10 L per minute.
3. Obtain maternal vital signs and assess the fetal heart rate (FHR).
4. Instruct on the actions and contraindications associated with the medication.
4
Explanation:
1. The client has refused epidural anesthesia but is authorized to receive butorphanol tartrate.
2. Routine oxygen administration is not indicated for administration of butorphanol tartrate to an asymptomatic client in labor.
3. Prior to obtaining maternal vital signs and assessing FHR, the nurse should advise the client as to the actions and contraindications associated with butorphanol tartrate.
4. Prior to administering the medication, the nurse must explain the pharmacologic effects of the medication.
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