A nurse is caring for a client in active labor.

Admission Assessment.

0200:. Gravida 1, Para 0 at 39 weeks gestation.

Presents with.

contractions occurring every 5 to 6 min, 45 to 60 seconds.

duration.

Cervical examination 4 cm dilated, 50% effaced.

Admit.

to the labor and delivery unit.

Nurses' Notes.

0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale.

of O to 10 with contractions.

Cervix 4 cm dilated, 50% effaced,with membranes intact.

0230:. The client reports increasing discomfort with contractions.

Cervix 5. cm dilated, 60% effaced, with membranes intact.

Contractions.

occurring every 5 min, 45 to 60 seconds duration.

0300:. Epidural anesthesia was initiated.

Cervix 7 cm dilated, 70% effaced,. with membranes intact.

Contractions occur every 4 to 5 min,60 seconds duration.

Vital Signs.

0200:. Temperature 36.9° C (98.4° F). Heart rate 86/min.

Respiratory rate 18/min.

BP 118/78 mm Hg. 0230:. Temperature 37° C (98.6° F). Heart rate 88/min.

Respiratory rate 20/min.

BP 120/80 mm Hg. 0300:. Temperature 37.1° C (98.8° F). Heart rate 90/min.

Respiratory rate 18/min.

BP 122/76 mm Hg. The nurse is assuming care for the client at 0305.

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

Choice A rationale:

Making decisions about health care on clients' behalf without their involvement violates the principle of patient autonomy. Patients have the right to be actively involved in decisions about their own care and treatment plans. Encouraging shared decision-making and respecting patients' choices are essential aspects of nursing advocacy.

Choice B rationale:

Promoting health care access is a fundamental aspect of advocacy in client care. Nurses should advocate for their patients' access to necessary healthcare services, treatments, and resources. This includes ensuring that patients have access to appropriate medical facilities, specialists, medications, and therapies. Advocating for health care access helps patients receive timely and appropriate care, improving their overall health outcomes.

Choice C rationale:

Encouraging clients to seek further information from the provider is crucial for informed decision-making. Providing patients with accurate and relevant information enables them to make educated choices about their health. Nurses can facilitate this process by clarifying medical information, explaining treatment options, and addressing patients' concerns. Informed patients are better equipped to actively participate in their care and advocate for their own needs.

Choice D rationale:

Addressing client needs when providing resources is an essential aspect of nursing advocacy. Nurses should assess their patients' individual needs and collaborate with other healthcare professionals to provide appropriate resources and support. This can include coordinating social services, arranging for home healthcare, or connecting patients with support groups. Meeting clients' needs ensures that they receive comprehensive care, promoting their overall well-being.

Choice E rationale:

Honoring family requests to withhold medical information can be ethically challenging. While family members play a significant role in a patient's life, confidentiality and patient autonomy must be respected. In most cases, healthcare providers should prioritize communicating directly with the patient, respecting their right to make decisions about their own health information. Exceptions may arise in situations involving legal guardianship or when patients are unable to communicate their preferences. However, the default approach should be to involve the patient directly in decisions about their healthcare information.

Choice A rationale:

Identifying possible precipitating factors related to the infections is the first step in addressing the issue of increased catheter infections. Understanding the potential causes, such as poor catheter insertion techniques, inadequate hygiene practices, or contaminated equipment, can help the nurse pinpoint the areas that need improvement. By identifying these factors, the nurse can implement targeted interventions to prevent future infections.

Choice B rationale:

Meeting with providers to discuss measures to decrease infections is a valid step, but it should come after identifying the specific factors contributing to the infections. Without a clear understanding of the root causes, the discussion with providers may lack focus and may not lead to effective solutions.

Choice C rationale:

Revising the current policy for catheter care can be considered after identifying the precipitating factors. Policy revision should be based on evidence-based practices and a thorough understanding of the issues contributing to the infections. Simply revising the policy without addressing the underlying causes may not lead to significant improvements.

Choice D rationale:

Scheduling nursing staff training for infection control procedures is an important step in preventing infections, but it should also follow the identification of specific issues related to the catheter infections. Training programs can be tailored to address the identified problems and provide targeted education to the staff members involved.