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
The PN should provide the information that it may be helpful to **try withholding fluids after supper and before bedtime**. Bedwetting is common and often runs in families. It can be upsetting, but most children and young people will grow out of it³. It’s not unusual for kids to wet the bed at night. Known formally as pediatric enuresis, uncontrolled nighttime urination affects as many as 5% to 10% of 7-year-olds in the United States.
Correct Answer is B
Explanation
Detoxification can be a difficult and potentially dangerous process, and it's important for the client to receive proper monitoring and medication management during this time. The hospital is equipped to provide this level of care and support. The practical nurse should explain this to the client and emphasize the importance of receiving proper care during detoxification.
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