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 C
Explanation
Albuminuria, or the presence of albumin in the urine, is an early sign of relapse in a toddler with minimal change nephrotic syndrome (MCNS) who has been treated with corticosteroids. MCNS is a kidney disorder that can cause the body to excrete too much protein in the urine, leading to albuminuria. The practical nurse should recognize this finding as an early sign of relapse and take appropriate action to manage the child's condition.
The other answers are incorrect because they are not directly related to the early signs of relapse in a toddler with minimal change nephrotic syndrome (MCNS) who has been treated with corticosteroids.
- Increased thirst is not a known early sign of relapse in MCNS.
- Tachypnea, or rapid breathing, is not a known early sign of relapse in MCNS.
- A rounded face can be a side effect of corticosteroid treatment, but it is not an early sign of relapse in MCNS.
Correct Answer is A
Explanation
A male client with paranoia can be expected to exhibit behavior such as being **openly hostile to others for no apparent reason**. Paranoia is a mental health condition characterized by intense and irrational mistrust or suspicion of others. This can lead to hostility and aggression towards others, even when there is no apparent reason for it.
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