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. Silence the bed alarm when visitors are at the client's bedside: Silencing the bed alarm, even with visitors present, eliminates an essential safety mechanism. The presence of visitors does not guarantee client supervision, and falls can still occur if the client attempts to get up unexpectedly.

B. Establish an elimination schedule for the client: Creating a toileting schedule helps reduce the likelihood of the client attempting to ambulate independently to the bathroom, which is a common time for falls. This proactive approach promotes safety and preserves dignity.

C. Allow the client to walk unassisted near the nursing station: Even when close to staff, allowing a fall-risk client to walk unassisted increases the chance of injury. Supervision does not replace physical support or assistive devices for those at risk.

D. Raise all four bed rails on the client's bed: Raising all four bed rails is considered a form of restraint and may increase injury risk if the client attempts to climb over them. Instead, using two rails and other fall precautions is safer and more appropriate.

Rationale:

A. Rotate staff members caring for the client: Clients with paranoid personality disorder often struggle with trust and may become more suspicious if care is inconsistent. Assigning consistent staff helps build therapeutic rapport and minimizes perceived threats.

B. Mix the medication with the client’s food items: Covertly administering medications violates the client’s autonomy and can worsen paranoia if discovered. Open, honest communication is essential when working with clients who have paranoid thoughts.

C. Speak in a neutral tone when addressing the client: A neutral, calm, and nonjudgmental tone reduces perceived hostility or manipulation. It supports the development of trust and helps avoid triggering defensive or suspicious behaviors.

D. Limit the client’s opportunities to socialize with others: Social interaction should not be restricted unless it poses a safety risk. Encouraging appropriate socialization may help reduce isolation and reinforce reality, even if the client has difficulty with interpersonal relationships.