A nurse is assisting with the care of a client who is in active labor.

Admission Assessment.

1130: Client admitted to labor and delivery.

Gravida 1, para 0 at 40. weeks of gestation.

Client presents with contractions every 5 to. 6 min, 30 to 40 seconds duration, 2+ intensity.

Client reports their water broke and the fluid was clear.

Positive for group B. streptococcus B-hemolytic at 37 weeks.

Sterile vaginal examination by RN. Cervix 5 cm dilated, 50% effaced.

0 station.

The nurse is assisting with the care of the client following the insertion of an epidural.

For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

Choice A rationale:

The nurse should encourage the client to be assertive. Dependent Personality Disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. One of the treatment goals is to help the client develop assertiveness skills to reduce their dependence on others. Encouraging assertiveness allows the client to express their needs and make decisions for themselves, which is an essential aspect of their therapeutic journey toward independence.

Choice B rationale:

Assuming responsibility for making the client's decisions would not be appropriate. It would further reinforce the client's dependent behavior and hinder their progress towards independence. The goal of therapy is to promote autonomy and self-reliance, not to perpetuate dependency.

Choice C rationale:

Maintaining a verbal no-harm contract with the client may be necessary in some cases, especially if the client exhibits self-harming behaviors. However, it is not a primary teaching point when educating the caregiver about managing a client with Dependent Personality Disorder. The focus should primarily be on helping the client develop assertiveness and self-reliance.

Choice D rationale:

Limiting the client's social interactions is not an appropriate intervention. Social support can be beneficial for individuals with Dependent Personality Disorder, as it can help them build self-confidence and reduce their excessive reliance on one individual. Isolating the client would not be in their best interest.

Choice A rationale:

A boggy fundus 3 fingerbreadths above the umbilicus is not an expected finding after receiving oxytocin for excessive vaginal bleeding. This finding could indicate uterine atony, which is a concern, but it is not a typical immediate response to oxytocin.

Choice B rationale:

The client reporting uterine cramping is an expected finding after receiving oxytocin. Oxytocin is often administered to stimulate uterine contractions and reduce bleeding, so uterine cramping is a positive response to the medication.

Choice C rationale:

Saturation of perineal pad in 15 minutes is not an expected finding after receiving oxytocin. Excessive bleeding would be a concern, and the nurse should monitor for signs of hemorrhage.

Choice D rationale:

The client reporting burning with urination is not an expected finding related to oxytocin administration. This symptom could be indicative of a urinary tract infection or another issue unrelated to oxytocin. It should be assessed and addressed separately.