A nurse is caring for a client who has been admitted to an antepartum unit.

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History and Physical

Day 1, 0900:

30-year-old client who is at 33 weeks of gestation, gravida 4 para 3. Maternal blood type is Rh positive. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks of gestation. No known allergies.

Nurses' Notes

Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge.

Uterine contractions every 8 min, palpate strong, duration 30 seconds.

FHR baseline is 145/min, minimal variability.

Cervical examination indicates 2 cm, 50% effaced, 0 station.

Membranes are intact.

CBC and urinalysis collected and sent to laboratory.

A. Gather supplies for a client's dressing change after removing the old dressing: This approach is inefficient and can lead to delays in care. Effective time management involves preparing all necessary supplies beforehand to minimize interruptions and ensure a smooth workflow.

B. Complete activities for one client before moving to the next client: Organizing care around each client and completing all required interventions in one visit promotes efficiency, reduces the risk of missed tasks, and allows better prioritization of nursing responsibilities.

C. Document assessment findings and interventions after providing care for a group of clients: Delaying documentation increases the risk of forgetting important details and can compromise patient safety. Timely documentation is essential for accurate communication and continuity of care.

D. Delay cleaning personal work area until the end of the shift: Maintaining an organized and clean work environment throughout the shift prevents clutter, reduces errors, and supports efficient care delivery. Postponing cleaning can hinder workflow and time management.

A. Request an interpreter of a different sex from the client: The sex of the interpreter should generally match the client’s preference to ensure comfort and cultural sensitivity. Automatically choosing a different sex could cause distress or reduce effective communication.

B. Direct attention toward the interpreter when speaking to the client: The nurse should speak directly to the client, maintaining eye contact and addressing them personally, rather than focusing on the interpreter. This promotes engagement and respects the client’s autonomy.

C. Review the facility policy about the use of an interpreter: Understanding the facility’s interpreter policies ensures the nurse follows proper procedures for obtaining professional language services, maintains confidentiality, and delivers accurate and effective communication for informed consent and care planning.

D. Request a family member or friend to interpret information for the client: Using family or friends as interpreters is discouraged due to risks of miscommunication, bias, or breach of confidentiality. Professional interpreters ensure accurate, unbiased communication.