A client who is in active labor is admitted with her cervix dilated to 3 cm with 50% effacement and the presenting part at 0 station. An hour later, she tells the practical nurse (PN) that she wants to go to the bathroom to empty her bladder. The nurse examines the client again and determines her vaginal exam is unchanged.
Which action should the PN implement?
Review the fetal heart rate pattern.
Assist the client up to the bathroom.
Check perineum for changes in "show" or discharge.
Obtain a straight catheter kit to empty her bladder.
The Correct Answer is B
If the client in active labor expresses a desire to empty her bladder and her vaginal exam is unchanged, the practical nurse (PN) should assist her up to the bathroom. An empty bladder can help facilitate labor progress.
Reviewing the fetal heart rate pattern (A) is important, but it is not the most appropriate action in response to the client's request to empty her bladder. Checking the perineum for changes in "show" or discharge (C) is also important, but it is not the most appropriate action in this situation. Obtaining a straight catheter kit to empty the client's bladder (D) may be necessary if she is unable to empty her bladder on her own, but assisting her up to the bathroom should be attempted first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Scoliosis screening is typically performed on early adolescent girls, as this is the age group that is most commonly affected by the condition. Early detection and intervention can help prevent the progression of scoliosis and improve outcomes.
Correct Answer is A
Explanation
Respiratory syncytial virus (RSV) is a highly contagious virus that can cause severe respiratory infections, especially in infants and young children. RSV is easily spread through contact with respiratory secretions from infected individuals, and can survive on surfaces for several hours. Therefore, it is important to avoid exposing other children to RSV, especially those who are under 6 months old or have a weakened immune system. The practical nurse (PN) should advise the mother not to take her infant to the birthday party to prevent the spread of RSV to other children. The PN can provide education on how to prevent the spread of RSV, such as washing hands frequently, avoiding close contact with sick individuals, and covering the mouth and nose when coughing or sneezing.
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