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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Correct Answer: D. Report the findings to the charge nurse.
Choice A rationale:
Monitoring the client's temperature hourly may be indicated if the client's condition deteriorates or if there are specific concerns about fever. However, the temperature of 99.8°F (37.66°C) is not significantly elevated and may not be the primary concern in this situation.
Choice B rationale:
Offering the client fluids frequently is a good nursing practice, but it is not the most important intervention in this case. The client's nonproductive cough and increased confusion need to be addressed and reported first.
Choice C rationale:
Providing care to moisten oral mucosa is important for maintaining oral health and preventing dryness and discomfort. However, it may not directly address the client's current symptoms of cough and confusion.
Choice D rationale:
Reporting the findings to the charge nurse is the most crucial intervention. The client's nonproductive cough and increased confusion may be indicative of an underlying issue, such as a respiratory infection or a change in neurological status. The charge nurse can initiate further assessments, notify the healthcare provider, and implement appropriate interventions to address the client's condition promptly. Timely reporting and communication are essential to ensure the client receives appropriate care.
Correct Answer is D
Explanation
Choice A rationale: While it is important to monitor the fetal heart rate, it does not directly address the client's immediate need to empty her bladder.
Choice B rationale: Obtaining a straight catheter kit to empty her bladder could be considered if the client is unable to void on her own, but it is not the first line of action if the client is able to ambulate.
Choice C rationale: Checking the perineum for changes in "show" or discharge is part of ongoing labor monitoring, but it does not address the client's immediate request.
Choice D rationale: Assisting the client up to the bathroom is appropriate. Ambulating to the bathroom is safe given the unchanged vaginal exam, and allowing the client to empty her bladder can help maintain bladder function and comfort.
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