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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The most important behaviors for the practical nurse (PN) to monitor in this situation are argumentativeness and use of profanity. These behaviors may indicate that the client is becoming agitated and may pose a risk to themselves or others. The PN should closely monitor the client's behavior and take appropriate action to ensure the safety of the client and others on the unit. The other behaviors listed may also be important to monitor, but argumentativeness and use of profanity are the most important in this situation
Correct Answer is C
Explanation
Answer: B. Limit play with the stuffed toy when out of the tent.
Rationale:
A) Spray the toy with disinfectant before placing it in the tent: Disinfecting the toy may not be necessary unless the toy is visibly soiled. Moreover, the use of disinfectants around the child may pose a risk of respiratory irritation, making this option inappropriate.
B) Limit play with the stuffed toy when out of the tent: This action is appropriate as it helps minimize the risk of cross-contamination and reduces exposure to potential allergens or irritants that may worsen the child's condition. Keeping the toy limited to the tent allows for a safer environment for the child.
C) Allow the child to have the stuffed toy in the tent: While having a favorite toy can provide comfort, it’s crucial to ensure that the toy does not harbor germs that could exacerbate the child's illness. In a mist tent, moisture can also promote mold growth on soft toys, so extra caution is necessary.
D) Ask the mother to wash the toy daily at home: While washing the toy is a good practice, this option does not directly address the immediate care in the hospital setting. Daily washing might not be feasible for the mother during the hospital stay, and it does not focus on minimizing exposure during the child’s hospitalization.
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