The licensed practical nurse (LPN) on the labor and delivery unit reports to the registered nurse (RN) that the woman's uterus, shortly after birth, is one finger breadth below the umbilicus and is displaced to the right of the abdomen. Which instruction by the RN to the LPN Indicates appropriate delegation?
"Vigorously massage the client's fundus until her fundus feels firmer."
"Assist the client to the bathroom so that she can empty her bladder."
"Obtain her vital signs, and I will come and check her fundus in a few minutes."
"Set an infusion pump in the room while I prepare oxytocin for infusion."
The Correct Answer is B
Rationale:
A. This is not appropriate for delegation. Fundal massage is an RN-level intervention because it involves assessment and therapeutic action for a potential postpartum complication (uterine atony or hemorrhage). It requires clinical judgment and monitoring for bleeding.
B. This is appropriate delegation to an LPN. Assisting with ambulation and toileting is within the LPN’s scope, and emptying the bladder can help correct uterine displacement caused by bladder distention. The LPN can perform this task safely under RN supervision.
C. While obtaining vital signs may be within LPN scope, delaying assessment of the fundus when the uterus is displaced and possibly at risk for hemorrhage is unsafe. The RN must assess the fundus promptly; delegating delay here is inappropriate.
D. Programming or setting up infusion pumps for high-alert medications like oxytocin requires RN judgment and verification. This task is not appropriate to delegate to an LPN without RN supervision.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. This approach is punitive and does not address the client’s underlying concern, which is a lack of trust. Confronting the client in this manner may escalate anxiety and further damage the nurse-client relationship.
B. This action reflects a collaborative and client-centered leadership approach. It actively involves the client in decision-making, validates their concerns, and promotes trust and transparency. By facilitating communication between the client and the healthcare team, the nurse supports informed consent and strengthens the therapeutic relationship.
C. Transferring the client does not resolve the underlying issue of mistrust with the healthcare team and may be disruptive or seen as avoidance rather than problem-solving.
D. While continuity of care is important, simply changing the nurse may not address the client’s lack of trust in the broader healthcare team or the specific concerns causing treatment refusal.
Correct Answer is ["B","C","E"]
Explanation
Rationale:
A. Tardiness is a performance concern but does not immediately compromise patient safety. While it should be addressed through counseling or disciplinary action, it is not an urgent safety issue compared to the direct care concerns.
B. Inadequate pain management for client 2 is an immediate patient care concern. Pain is a priority problem, and failure to administer or evaluate analgesia appropriately can cause unnecessary suffering and indicate a lapse in professional practice.
C. Client 1’s potassium level of 3.1 mEq/L is critically low. The nurse failed to notify the provider, which poses a direct risk to the client’s cardiac safety. Addressing this oversight is urgent because it represents a life-threatening situation.
D. The wrinkled uniform is a professional appearance issue. While it may reflect stress, fatigue, or personal neglect, it does not pose an immediate threat to patient safety.
E. Documenting a head-to-toe assessment that did not occur is false documentation and a serious breach of nursing practice. Falsifying records can compromise patient care, legal compliance, and institutional integrity. This is an urgent issue requiring immediate intervention.
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