A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Client reports lower back pain and pinkish vaginal discharge.

• Explanation: Lower back pain and pinkish discharge can indicate preterm labor, especially given the client’s history of a previous preterm birth.

Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.

• Explanation: Frequent and strong contractions suggest that labor may be progressing, which is concerning at 33 weeks gestation and needs close monitoring.

FHR baseline 145, minimal variability.

• Explanation: Minimal variability in the fetal heart rate (FHR) can be a sign of fetal distress or a lack of fetal well-being, warranting further evaluation.

Cervical exam indicates 2 cm, 50% effaced, 0 station.

• Explanation: Cervical dilation and effacement at 33 weeks gestation indicate that labor is progressing. Given the client's history of preterm birth, this finding is concerning and requires intervention to try to prevent another preterm delivery.

Answer:

1. Review the skill level and qualifications of each AP.

2. Communicate appropriate tasks to the APs with specific expectations.

3. Monitor progress of task completion with each AP.

4. Evaluate the APs' performance of each task.

Explanation:

1. Review the skill level and qualifications of each AP: Before delegating tasks to the assistive personnel (APs), the nurse should assess their individual skills, training, and qualifications to determine their capabilities. This step ensures that tasks are assigned to the APs who are competent and trained to perform them safely and effectively.

2. Communicate appropriate tasks to the APs with specific expectations: The nurse should clearly communicate the tasks to be delegated to the APs, providing specific instructions and expectations regarding how each task should be performed. This step helps prevent misunderstandings and ensures that the APs understand what is expected of them.

3. Monitor progress of task completion with each AP: Once tasks are assigned, the nurse should periodically check on the progress of each AP in completing their assigned tasks. Monitoring helps the nurse ensure that tasks are being performed correctly and in a timely manner.

4. Evaluate the APs' performance of each task: After the tasks are completed, the nurse should evaluate the performance of each AP. This evaluation involves assessing whether the tasks were performed according to the specific expectations communicated earlier and whether there were any issues or deviations during task completion. The evaluation helps identify areas for improvement and provides feedback for the APs to enhance their skills and performance.