A nurse is assisting with the care of a client.

Exhibits

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Communicate advance directives status via the medical record and shift report.

Provide the client with written information about advance directives.

Inform the client that an advance directive discontinues further care.

Instruct the client that an advance directive is a legal document and must be honored by care providers.

Document that the provider discussed do-not-resuscitate status with the client.

Initiate a power of attorney for health care document.

Answer and Explanation

Correct Answer : A,B,D,E

A. Communicate advance directives status via the medical record and shift report. The nurse is responsible for ensuring that all members of the healthcare team are aware of the client’s advance directives. Documenting this information in the medical record and shift report helps guide care in accordance with the client’s wishes.
B. Provide the client with written information about advance directives. Clients have the right to receive information about advance directives, including living wills and do-not-resuscitate (DNR) orders. The nurse should provide educational materials to help the client make informed decisions.
C. Inform the client that an advance directive discontinues further care. An advance directive does not automatically discontinue all medical care. It provides instructions regarding specific interventions the client wishes to accept or decline, such as resuscitation, mechanical ventilation, or artificial nutrition. The nurse should clarify this to avoid misconceptions.
D. Instruct the client that an advance directive is a legal document and must be honored by care providers. Advance directives are legally binding documents that must be followed by healthcare providers. The nurse should reinforce that the client’s wishes, as stated in the directive, will be respected.
E. Document that the provider discussed do-not-resuscitate status with the client. Proper documentation is essential to ensure the client's preferences regarding resuscitation and end-of-life care are acknowledged and followed. The nurse should record discussions regarding advance directives in the medical record.
F. Initiate a power of attorney for health care document. The nurse does not have the authority to initiate a power of attorney for health care. The client must complete this legal document independently or with legal assistance, and it typically requires notarization or witness signatures. The nurse can provide information about it but cannot create or execute it on the client’s behalf.

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Correct Answer is B

Explanation

A. "The website was last updated 3 years ago." Medical information evolves rapidly, and outdated sources may contain inaccurate or obsolete data. Regular updates improve credibility.
B. "The author cites references to statements made." Citing references supports the accuracy and credibility of medical information. Reliable sources should provide evidence-based content backed by research or reputable organizations.
C. "The website URL is listed as .com." Commercial websites (.com) can contain valid information, but they may also prioritize marketing over accuracy. Government (.gov), educational (.edu), and nonprofit (.org) sites tend to be more reliable.
D. "The author's name is listed without credentials." Without credentials, it is difficult to verify the author's expertise. Reliable medical sources should have content written or reviewed by professionals with relevant qualifications.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for Correct Options:

Late decelerations on fetal heart rate (FHR) – First Priority

Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery.

Positive Group B streptococcus (GBS) status – Second Priority

The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery.

Rationale for Incorrect Options:

Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort.
Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation.
Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening.
Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.

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A nurse is assisting with the care of a client. Exhibits Select the 4 responsibilities the nurse has in relation to the client's advance directives.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

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A nurse is assisting with the care of a client.

Exhibits

Select the 4 responsibilities the nurse has in relation to the client's advance directives.