A client who is 39 weeks gestation calls the labor and delivery unit to report that she is experiencing mild, irregular contractions. She tells the practical nurse (PN) that the healthcare provider examined her in the clinic today, and her cervix was 3 cm dilated, with intact membranes, and the presenting part was at -1 station. Which intervention should the PN implement?
Tell her to empty her bladder and call if she has a bloody show.
Direct her to come to the unit for impending delivery.
Ask the charge nurse for further instructions.
Encourage ambulation until the contractions are regular.
The Correct Answer is A
The correct answer is choice A: Tell her to empty her bladder and call if she has a bloody show.
Choice A rationale:
The client is 39 weeks gestation and experiencing mild, irregular contractions. The fact that her cervix is already 3 cm dilated and the presenting part is at -1 station indicates that she is in early labor. Emptying the bladder can help relieve pressure on the cervix and promote progress in labor. Instructing her to call if she has a bloody show is essential because it could indicate that her labor is advancing, and she may need to come to the labor and delivery unit soon.
Choice B rationale:
Directing her to come to the unit for impending delivery is not appropriate at this stage, as she is only experiencing mild, irregular contractions and is likely in early labor. Coming to the unit too early may lead to unnecessary interventions and discomfort for the client.
Choice C rationale:
Asking the charge nurse for further instructions is not necessary in this situation. The client's condition is not emergent, and the practical nurse can handle the situation appropriately based on the information provided.
Choice D rationale:
Encouraging ambulation until the contractions are regular might be beneficial in some cases to promote labor progress. However, given that the client is already 3 cm dilated and experiencing mild, irregular contractions, it's better to address the issue of bladder emptying and potential bloody show.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the group of children that the PN should screen for scoliosis because they are at the highest risk of developing this condition. Scoliosis is a lateral curvature of the spine that usually occurs during the growth spurt before puberty. Girls are more likely than boys to have scoliosis, and the condition tends to worsen during adolescence.
A. High school boys are not at high risk of scoliosis and do not need to be screened unless they have signs or symptoms of the condition.
B. High school girls are at lower risk of scoliosis than middle school girls because they have completed most of their growth spurt and their condition is less likely to progress.
C. Middle school boys are at lower risk of scoliosis than middle school girls because they have a slower growth rate and a later onset of puberty.
Correct Answer is D
Explanation
The correct answer is choice D. Don non-sterile gloves when performing direct care.
Choice A rationale:
Placing a surgical mask on the client during transport is not necessary for preventing the spread of Clostridium difficile. C. difficile is primarily spread through contact with contaminated surfaces and not through airborne transmission.
Choice B rationale:
Keeping the door closed to the client’s room at all times is not required for C. difficile infection. The focus should be on contact precautions rather than airborne precautions.
Choice C rationale:
Wearing a particulate respirator mask is not needed for C. difficile, as it is not an airborne pathogen. Standard contact precautions are sufficient.
Choice D rationale:
Donning non-sterile gloves when performing direct care is essential to prevent the spread of C. difficile. The spores can be transmitted via the hands of healthcare workers, so wearing gloves helps to minimize this risk.
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