A nurse is caring for a client who is in active labor.
The nurse should notify the provider for which of the following findings?

 

The correct answer is Choice B

Choice A rationale: Advance directives are voluntary and revocable; clients can change their decisions at any time as long as they are mentally competent.

Choice B rationale: Discussing advance directives with family ensures clarity, reduces future conflict, and supports informed decision-making aligned with the client’s wishes.

Choice C rationale: Witnesses are typically required, but a partner’s presence is not legally mandated unless designated as a healthcare proxy.

Choice D rationale: Notarization is not universally required; validity depends on state laws, and many jurisdictions accept signed and witnessed documents without attorney involvement.

Choice A rationale:

Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.

Choice B rationale:

Performing a fundal massage is incorrect choice in this scenario.

Choice C rationale:

Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.

Choice D rationale:

Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.