A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery.
Which action is most important for the nurse to implement?
Discuss the character of labor from endogenous vs. exogenous oxytocin.
Ask the healthcare provider to discuss the issue with the client.
Discuss alternative ways to support the client's birth plan.
Explain the indications for induction related to post-term pregnancy.
The Correct Answer is C
Choice A rationale:
Discuss the character of labor from endogenous vs. exogenous oxytocin. While it is important to educate the client about the difference between endogenous (naturally occurring) and exogenous (administered) oxytocin, this information may not address the client's primary concern. The client is refusing the prescribed oxytocin infusion and wants a "natural" delivery. Therefore, discussing alternative ways to support her birth plan is more pertinent.
Choice B rationale:
Ask the healthcare provider to discuss the issue with the client. Involving the healthcare provider in the discussion is a reasonable step, but it should not be the first action taken. The nurse can initiate a conversation with the client to explore her concerns and preferences before escalating the issue to the healthcare provider.
Choice C rationale:
Discuss alternative ways to support the client's birth plan. This is the correct choice because it directly addresses the client's refusal of the oxytocin infusion and desire for a "natural" delivery. Exploring alternative methods for inducing or facilitating labor in a way that aligns with the client's birth plan is essential.
Choice D rationale:
Explain the indications for induction related to post-term pregnancy. Explaining the indications for induction is important for educating the client about the medical reasons behind the prescribed treatment. However, this information may not immediately address the client's refusal of the oxytocin infusion. The nurse should first explore the client's concerns and preferences regarding her birth plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Impaired physical mobility is a significant concern in Parkinson's disease due to bradykinesia and tremors. However, it does not pose an immediate threat to life when compared to potential airway and respiratory complications.
Choice B rationale: Aspiration is the highest priority according to the ABC (Airway, Breathing, Circulation) framework. Parkinson's causes dysphagia and impaired laryngeal reflexes, making silent aspiration and subsequent pneumonia a life-threatening risk for the client.
Choice C rationale: Constipation is common due to decreased GI motility and side effects of dopaminergic medications. While it causes discomfort and potential impaction, it is a physiological need that ranks lower than respiratory safety.
Choice D rationale: Self-care deficits in hygiene and dressing affect the client's quality of life and independence. In the hierarchy of care, these functional limitations are addressed only after the client's physical safety and airway are secured.
Correct Answer is B
Explanation
Choice B rationale:
Explaining that the client will start to lose consciousness and the body systems will slow down is the best response. This is a common pattern in the dying process, and it provides the wife with a clear and compassionate explanation of what to expect as her husband's death approaches.
Choice A rationale:
Gathering information regarding how long it will take for the children to arrive is important but does not address the immediate need for information on the dying process.
Choice C rationale:
Offering to discuss the client's health status with each of the adult children is a good approach for involving them in their father's care but does not provide the immediate information the wife is seeking.
Choice D rationale:
Reassuring the spouse that the healthcare provider will notify when to call the children does not offer information about the dying process itself, which is what the wife is interested in understanding.
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