A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?

Rationale:

• Excessive spending habits: This behavior is hallmark for mania, where impaired judgment, impulsivity, and inflated self-esteem lead to reckless financial decisions.
• Hallucinations: Hallucinations, especially visual or auditory ones, are classic signs of psychosis. They indicate a break from reality and are not a diagnostic feature of mania alone unless psychotic features are present.
• Pressured speech: Pressured, rapid, and loud speech is a diagnostic feature of mania, reflecting heightened psychomotor activity and racing thoughts.
• Lack of sleep: Insomnia without fatigue is typical in mania. Clients may stay awake for days with increased energy levels and no perceived need for rest.
• Disorganized thought process: This can appear in both mania and psychosis. In mania, it stems from flight of ideas and distractibility. In psychosis, it results from impaired reality testing and cognitive disintegration.

Rationale:

A. You should not delegate this task because it requires nursing judgment: Weighing clients is a routine, non-invasive task that does not involve clinical decision-making. It does not require nursing judgment and is appropriate for delegation if the AP is competent.

B. You can delegate this task to an AP for new clients before performing a nursing assessment: Initial assessments must be performed by a licensed nurse. Weighing can be part of the assessment, but the nurse should first evaluate the client to determine whether delegation is appropriate.

C. You can delegate this task if the AP has been trained to use our scales: Delegation depends on the AP’s competence and familiarity with facility equipment. If trained, the AP can safely and accurately weigh clients, freeing the nurse for tasks requiring professional judgment.

D. You should not delegate this task because you have the capability to obtain clients weights: Delegation decisions should be based on scope of practice and task appropriateness, not whether the nurse is physically able to perform the task. Efficient delegation supports safe and effective care delivery.