A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs.
Which intervention should the home health nurse implement to ensure adequate care for all clients?

The correct answer is B. "You seem quite frightened right now."

Choice A rationale:

This statement dismisses the client's feelings and may not provide the reassurance they need. It could also escalate the situation if the client feels misunderstood or ignored.

Choice B rationale:

This response acknowledges the client's emotions and validates their experience, which can help build trust and de-escalate the situation. It shows empathy and understanding, which are crucial in managing delusions.

Choice C rationale:

While this statement aims to reassure the client, it may not address their immediate emotional state. The client might not feel safe despite being told they are, so it might not be as effective in calming them down.

Choice D rationale:

This response could inadvertently reinforce the client's delusions by implying that their fears are valid and that the nurse should take action based on those delusions. It might also confuse the client further.

Choice A rationale:

Discuss the character of labor from endogenous vs. exogenous oxytocin. While it is important to educate the client about the difference between endogenous (naturally occurring) and exogenous (administered) oxytocin, this information may not address the client's primary concern. The client is refusing the prescribed oxytocin infusion and wants a "natural" delivery. Therefore, discussing alternative ways to support her birth plan is more pertinent.

Choice B rationale:

Ask the healthcare provider to discuss the issue with the client. Involving the healthcare provider in the discussion is a reasonable step, but it should not be the first action taken. The nurse can initiate a conversation with the client to explore her concerns and preferences before escalating the issue to the healthcare provider.

Choice C rationale:

Discuss alternative ways to support the client's birth plan. This is the correct choice because it directly addresses the client's refusal of the oxytocin infusion and desire for a "natural" delivery. Exploring alternative methods for inducing or facilitating labor in a way that aligns with the client's birth plan is essential.

Choice D rationale:

Explain the indications for induction related to post-term pregnancy. Explaining the indications for induction is important for educating the client about the medical reasons behind the prescribed treatment. However, this information may not immediately address the client's refusal of the oxytocin infusion. The nurse should first explore the client's concerns and preferences regarding her birth plan.