A client who is 39 weeks gestation calls the labor and delivery unit to report that she is experiencing mild, irregular contractions. She tells the practical nurse (PN) that the healthcare provider examined her in the clinic today, and her cervix was 3 cm dilated, with intact membranes, and the presenting part was at -1 station. Which intervention should the PN implement?

Tell her to empty her bladder and call if she has a bloody show.

Direct her to come to the unit for impending delivery.

Ask the charge nurse for further instructions.

Encourage ambulation until the contractions are regular.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: Tell her to empty her bladder and call if she has a bloody show.

Choice A rationale:

The client is 39 weeks gestation and experiencing mild, irregular contractions. The fact that her cervix is already 3 cm dilated and the presenting part is at -1 station indicates that she is in early labor. Emptying the bladder can help relieve pressure on the cervix and promote progress in labor. Instructing her to call if she has a bloody show is essential because it could indicate that her labor is advancing, and she may need to come to the labor and delivery unit soon.

Choice B rationale:

Directing her to come to the unit for impending delivery is not appropriate at this stage, as she is only experiencing mild, irregular contractions and is likely in early labor. Coming to the unit too early may lead to unnecessary interventions and discomfort for the client.

Choice C rationale:

Asking the charge nurse for further instructions is not necessary in this situation. The client's condition is not emergent, and the practical nurse can handle the situation appropriately based on the information provided.

Choice D rationale:

Encouraging ambulation until the contractions are regular might be beneficial in some cases to promote labor progress. However, given that the client is already 3 cm dilated and experiencing mild, irregular contractions, it's better to address the issue of bladder emptying and potential bloody show.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

This is the best action that describes the responsibility of the PN because it ensures that the client has given informed consent for the invasive examination and that the consent form is valid and documented. The PN should verify that the provider has explained the examination, its risks and benefits, and alternative options to the client and that the client has agreed to proceed.

A. Explaining the examination and asking the client to sign the consent form is not the responsibility of the PN but of the provider who will perform the examination.

B. Obtaining the medical record for the correct signed consent form prior to the examination is not enough to ensure informed consent and may not involve any interaction with the client.

C. Asking if the client understands the exam and why the consent form must be signed is not enough to ensure informed consent and may not address any questions or concerns that the client may have.

A. “Come into the recreation area. We have your favorite card game and I will play it with you." B. "Why do you want to stay in your room today?” C. "I know you are sad about not seeing your family as often, but they are visiting as much as they can.” D. “May I sit with you for a while?"

Correct Answer is D

Explanation

This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and oﬀers companionship, which can help reduce isolation and loneliness.

The other options are not correct because:

A. This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.

B. This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.

C. This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

Correct Answer is D

Explanation

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

Correct Answer is D

Explanation

What is most important for the practical nurse (PN) to include when performing pain assessment after giving an analgesic?

The practical nurse (PN) is assisting with the preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?

Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?

Which information should the practical nurse (PN) collect during admission assessment of a terminally ill client to an acute care facility?

A female client taking a liquid iron preparation expresses concern that her tooth color has darkened since starting the medication. Which action should the practical nurse (PN) implement?

An unlicensed assistive personnel (UAP) is completing an orientation assignment and is caring for a client who needs assistance with bathing. What is the best way for the practical nurse (PN) to evaluate this UAP's performance?

A male client atends a community support program for mentally impaired and chemical abusing clients. The client tells the practical nurse (PN) that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client?