A nurse is caring for a 26-year-old female client who is in active labor in the labor and delivery unit.

The client has requested epidural anesthesia, and it has been administered to manage her pain during labor. The nurse is now monitoring her condition closely.

Exhibits

Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving epidural anesthesia.

Choice A rationale

Disagreeing with the client's delusions and setting clear limits on talking about it may cause the client to become defensive and anxious, worsening the situation.

Choice B rationale

Presenting a personal perception of reality in a nonconfrontational manner helps the client feel understood and supported while gently guiding them back to reality. It is an effective approach to managing delusions.

Choice C rationale

Agreeing with the client's delusions and asking open-ended questions reinforces the delusional thinking and may not be helpful in the long term.

Choice D rationale

Immediately informing the healthcare provider about the delusional episode may be necessary if the delusions pose a risk, but it does not provide immediate support to the client.

Rationale for correct answers

Neglect: The client’s condition and living situation indicate neglect. The client is frail, has poor hygiene, unkempt hair, dry skin, and visible pressure injuries. The daughter, who is the primary caregiver, admits to being overwhelmed and neglecting the client’s needs, such as hygiene and repositioning. Neglect is defined as the failure to provide necessary care, assistance, and supervision to a dependent individual, leading to harm or potential harm.

Adult Protective Services: As a mandated reporter, the nurse must report the signs of elder mistreatment to Adult Protective Services (APS). APS is responsible for investigating reports of abuse, neglect, and exploitation of elderly or disabled adults. Reporting to APS ensures that the client receives the necessary intervention and support to address the neglect and improve her quality of life.

Rationale for incorrect answers

Abandonment: Abandonment refers to deserting an elderly person, leaving them without the necessary care and support. In this case, the client has not been deserted; her daughter is present and attempting to provide care, although she is overwhelmed and neglectful. Therefore, abandonment is not the correct answer.

Physical abuse: Physical abuse involves the intentional use of physical force that results in bodily injury, pain, or impairment. There is no evidence of physical abuse in this case. The client’s condition is due to neglect, not physical harm inflicted by another person.

Self-neglect: Self-neglect occurs when an individual fails to meet their own basic needs, such as personal hygiene, nutrition, or medical care. In this scenario, the client is dependent on her daughter for care and unable to provide for herself due to limited mobility. The neglect is not self-imposed but rather due to the caregiver's inability to meet her needs.