A client who is in active labor is admitted with her cervix dilated to 3 cm with 50% effacement and the presenting part at 0 station. An hour later, she tells the practical nurse (PN) that she wants to go to the bathroom to empty her bladder. The nurse examines the client again and determines her vaginal exam is unchanged.
Which action should the PN implement?
Review the fetal heart rate pattern.
Assist the client up to the bathroom.
Check perineum for changes in "show" or discharge.
Obtain a straight catheter kit to empty her bladder.
The Correct Answer is B
If the client in active labor expresses a desire to empty her bladder and her vaginal exam is unchanged, the practical nurse (PN) should assist her up to the bathroom. An empty bladder can help facilitate labor progress.
Reviewing the fetal heart rate pattern (A) is important, but it is not the most appropriate action in response to the client's request to empty her bladder. Checking the perineum for changes in "show" or discharge (C) is also important, but it is not the most appropriate action in this situation. Obtaining a straight catheter kit to empty the client's bladder (D) may be necessary if she is unable to empty her bladder on her own, but assisting her up to the bathroom should be attempted first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The best response for the PN to provide is that **an immunization may be administered for hepatitis B, and a consent form must be signed**. Phytonadione is a form of vitamin K that is given to newborns to prevent vitamin K deficiency bleeding (VKDB)¹. Vitamin K should be administered to all newborn infants weighing>1500 g as a single, intramuscular dose of 1 mg within 6 hours of birth¹. However, this is not the only injection your baby may receive while in the newborn nursery. An immunization for hepatitis B may also be administered before you can go home⁴.
Correct Answer is B
Explanation
Placenta previa is a condition in which the placenta partially or completely covers the cervix, which can lead to vaginal bleeding during pregnancy. In severe cases, this bleeding can be life-threatening and can lead to hemorrhage. Therefore, the PN should closely monitor the client for any signs of bleeding or hemorrhage, such as excessive vaginal bleeding, hypotension, tachycardia, or signs of shock. The PN should also ensure that the client receives appropriate medical interventions and that emergency measures are in place in case of sudden bleeding or hemorrhage.
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