A nurse is caring for a client who is nulliparous and in the first stage of labor. The last
internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?

A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.

B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.

C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.

D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.

A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.