A nurse is caring for a client who is receiving oxytocin and notes that the electronic fetal monitor shows persistent late decelerations. Which of the following actions should the nurse take?

Rationale:

A. "My provider will make my health care decisions if I complete advance directives.": Advance directives are designed to communicate the client’s own wishes regarding medical care, not to give the provider decision-making authority. The client retains the right to guide their care through these legal documents.

B. "A living will is a document that includes my wishes about health care decisions.": This statement demonstrates understanding because a living will specifies the client’s preferences for medical treatments, such as resuscitation or life-sustaining measures, in the event they are unable to communicate their wishes.

C. "My partner needs to be present as a witness when I sign a living will.": Witness requirements vary by state, but typically a living will requires impartial adult witnesses, not necessarily a partner, to prevent conflicts of interest. Believing the partner must be present reflects a misunderstanding of legal requirements.

D. "Advance directives outline who inherits my material possessions in the event of my death.": This describes a will, not an advance directive. Advance directives pertain to medical care decisions, not the distribution of property or assets.

Rationale:

A. Paradoxical chest movement: Paradoxical chest movement is typically associated with flail chest, where multiple rib fractures cause a segment of the chest wall to move in the opposite direction during breathing. It is not a characteristic finding of tension pneumothorax, which involves intrathoracic pressure buildup rather than rib instability.

B. Bilateral crackles: Bilateral crackles are usually indicative of fluid in the alveoli, such as in pulmonary edema or pneumonia. Tension pneumothorax generally causes decreased or absent breath sounds on the affected side, not crackles, due to lung collapse.

C. Asymmetry of the chest: Tension pneumothorax often causes visible asymmetry of the chest because the affected side may appear distended while the other side may appear sunken. The increased intrathoracic pressure pushes mediastinal structures toward the unaffected side, making chest asymmetry a hallmark sign.

D. Blood-tinged sputum: Blood-tinged sputum is more commonly seen with pulmonary infections, trauma to the airway, or pulmonary embolism. It is not a primary manifestation of tension pneumothorax, which is primarily characterized by respiratory distress and unilateral findings.