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 C
Explanation
The correct answer is Choice C. Place the ID bands on the infant and mother.
Choice A rationale:
While obtaining the infant's vital signs is important, it is not the priority action before transporting the baby to the nursery. Placing ID bands on the infant and mother ensures proper identification and prevents mix-ups during transportation, which is crucial in the nursery setting.
Choice B rationale:
Administering vitamin K injection is also essential but not the immediate priority before transporting the baby. Vitamin K administration helps prevent bleeding disorders in newborns, but ensuring proper identification and security come first.
Choice C rationale:
The correct choice. Placing ID bands on the infant and mother is the most important action before transporting the baby to the nursery. This step ensures accurate identification and matching between the baby and the mother, preventing any confusion or errors in the hospital setting.
Choice D rationale:
Observing the infant latching onto the breast is important for promoting breastfeeding, but it can be done after ensuring proper identification and safety measures have been taken.
Correct Answer is D
Explanation
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
A. An ankle ulcer that is healing slowly is not a major risk factor for falls and may not affect the client's mobility or balance.
B. History of alcohol abuse and cigarette smoking is not a major risk factor for falls unless the client is currently intoxicated or has a chronic lung disease that impairs oxygenation or cognition.
C. Recent weight gain of twenty pounds is not a major risk factor for falls unless it causes joint pain, edema, or difficulty moving.
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