A nurse is caring for a 26-year-old gravida 2 para 1 client in the labor and delivery unit.

Exhibits

Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have at least one response selected.

Choice A rationale

Explaining the ELISA test for confirmation is unnecessary as the client is already confirmed HIV positive. Repeating the test may cause confusion and anxiety without offering additional benefit at this stage.

Choice B rationale

Identifying support systems in the client's life is crucial for addressing the emotional and psychological impact of being HIV positive and a victim of rape. Support systems, such as family, friends, or support groups, can provide the necessary emotional support and practical assistance to help the client cope with the challenges.

Choice C rationale

Inquiring about plans to further education may not be timely or appropriate in the context of the client's current emotional state. The priority should be addressing the client's immediate mental health needs and ensuring they have adequate support systems in place.

Choice D rationale

Exploring feelings of hope for the future is important but may not be the immediate priority. The client is currently experiencing significant emotional distress, so addressing their immediate mental health needs and ensuring support is a higher priority.

Choice A rationale

The nurse’s signature on the surgical consent form does not verify the client’s understanding of the procedure. This responsibility lies with the physician or surgeon, who must ensure that the client is fully informed about the nature, risks, benefits, and alternatives of the procedure. The nurse’s role is to witness the client’s signature, confirming that the client has signed the form without coercion and is competent to do so.

Choice B rationale

The client’s competence to sign the consent form is a crucial aspect that the nurse witnesses. By signing as a witness, the nurse attests that the client is mentally sound and capable of making informed decisions about their medical care. This includes verifying that the client is not under the influence of substances that could impair judgment and that they understand the nature of the consent they are giving.

Choice C rationale

The client voluntarily granting permission for the procedure is another key element of the nurse’s witnessing role. The nurse’s signature confirms that the client has signed the consent form of their own free will, without any undue pressure or coercion. This ensures the validity of the consent and protects the client’s rights and autonomy in making healthcare decisions.

Choice D rationale

The explanation of the procedure, its necessity, and potential outcomes are the responsibility of the surgeon or physician. The nurse does not provide this detailed explanation but ensures that the client has had the opportunity to receive this information from the appropriate healthcare provider. The nurse’s signature does not verify that the surgeon has explained the procedure; it simply confirms the witnessing of the client’s signature.

Choice E rationale

Understanding the risks and benefits of the procedure is part of the informed consent process, which the physician or surgeon must explain to the client. The nurse’s role is to witness the client’s signature, ensuring that the client has had the opportunity to receive this information. The nurse’s signature does not confirm the client’s understanding of these details but indicates that the consent was signed voluntarily and competently.