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 A
Explanation
Newborns have a stump of the umbilical cord attached to their belly button which eventually falls off within 1-2 weeks. During this time, it is important to keep the area clean and dry to prevent infection. The PN should instruct the parents to clean the area with water and a clean cloth or cotton swab, and then gently pat the area dry with a clean towel. The parents should also be advised to avoid using any harsh soaps, lotions, or alcohol on the cord stump, as this can cause irritation or delay the healing process. It is not recommended to cover the cord stump with a sterile dressing unless specifically instructed to do so by a healthcare provider.
Correct Answer is B
Explanation
Repeated visits to multiple emergency departments for various injuries or complaints can be a red flag for possible child abuse. The other options may indicate other issues or concerns, but they do not provide as much reason to suspect child abuse as the history of repeated visits to different emergency departments. It is important for healthcare providers to remain vigilant for signs of child abuse and to report any suspicions to the appropriate authorities.
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