A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?

Rationale:

A. A client who requests assistance to use the bedside commode: This is a routine activity that falls within the scope of practice for assistive personnel. As long as the AP follows standard safety procedures, there is no immediate need to report this to the nurse.

B. A client who requests to sit in the bedside chair while watching TV: Allowing a client to sit up in a chair is within the AP’s role, provided the client is stable and fall precautions are followed. It does not require nurse notification unless there are complications.

C. A client who has a prescription for compression stockings and did not receive them: This indicates a potential lapse in prescribed therapy, which could increase the risk of complications like deep vein thrombosis. The nurse must be informed to evaluate and correct the omission promptly.

D. A client who consumes all the food from their meal tray: Reporting full meal consumption is not necessary unless the client is on a monitored diet or has specific nutritional concerns. In most cases, this is expected and requires only standard documentation.

Rationale:

A. Limit your fluid intake to 500 milliliters per day: Restricting fluids to this extent can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence symptoms. Maintaining adequate hydration is essential during bladder retraining.

B. Plan to urinate every 3 hours while you are awake: Scheduled voiding every 2 to 3 hours helps train the bladder to hold urine for longer intervals and reduces urgency episodes. This is a core component of effective bladder retraining for urge incontinence.

C. Decrease your intake of cranberry juice: Cranberry juice may help prevent urinary tract infections, though its benefit in incontinence management is limited. There is no need to avoid it unless advised for another reason, as it is not a known bladder irritant.

D. Take your diuretic medication with your evening meal: Taking diuretics late in the day increases nighttime urine production, leading to nocturia and disturbed sleep. Diuretics should be taken in the morning to align with daytime urinary patterns and reduce bladder strain at night.