A nurse is caring for a patient who is in labor and has an epidural anesthesia block. The patient’s blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min.
Which of the following is the priority nursing action?

Choice A rationale

Engaging in conversation with the patient during wound care can provide emotional support by distracting the patient from the pain and discomfort associated with the procedure. It also helps to build a therapeutic relationship, which is crucial in the healing process.

Choice B rationale

While ensuring the patient’s room is kept tidy by support staff is important for maintaining a clean and safe environment, it does not directly provide emotional support to the patient.

Choice C rationale

Keeping the patient’s family informed about his condition can provide reassurance and reduce anxiety, but it does not directly provide emotional support to the patient.

Choice D rationale

Rotating the nursing staff can provide the patient with varied interactions, but it may not necessarily provide emotional support. Consistency in care providers can often be more beneficial in building trust and rapport.

Choice A rationale

Urinary retention refers to the inability to empty the bladder completely. While it can cause discomfort and bloating, it does not typically result in dark amber, cloudy urine with an unpleasant odor.

Choice B rationale

Urinary incontinence is the loss of bladder control, leading to the involuntary leakage of urine. It does not cause the urine to become dark amber, cloudy, or have an unpleasant odor.

Choice C rationale

A urinary tract infection (UTI) is an infection in any part of the urinary system — kidneys, bladder, urethra. Most UTIs are caused by bacteria, but they can also be caused by viruses or fungi. Symptoms of a UTI often include cloudy, dark, or strong-smelling urine.

Choice D rationale

Urinary frequency refers to needing to urinate more often than usual. It can be a symptom of many different issues, including a UTI, but on its own, it does not cause the urine to become dark amber, cloudy, or have an unpleasant odor.