A nurse is caring for a client who is in active labor.
The nurse should notify the provider for which of the following findings?

Choice A rationale:

Asking the client directly about the hallucinations is essential in understanding the nature and content of the hallucinations. This information is crucial for the nurse to assess the client's mental state accurately and plan appropriate interventions. Direct communication helps establish trust and rapport with the client, making them more likely to share their experiences.

Choice B rationale:

Avoiding eye contact can create a sense of disconnection and may increase the client's anxiety. Establishing eye contact, on the other hand, communicates empathy and attentiveness, which are essential in therapeutic communication.

Choice C rationale:

Encouraging the client to lie down in a quiet room might not be the most appropriate action, as it does not address the hallucinations directly. It's important to address the hallucinations and help the client cope with them effectively.

Choice D rationale:

Referring to the hallucinations as if they are real might validate the client's experience but can also perpetuate the hallucinations. The nurse should acknowledge the client's feelings without reinforcing the false beliefs. Providing reality-based perspectives and encouraging the client to explore the origin of these hallucinations can be more beneficial.

The correct answer is Choice B

Choice A rationale: Advance directives are voluntary and revocable; clients can change their decisions at any time as long as they are mentally competent.

Choice B rationale: Discussing advance directives with family ensures clarity, reduces future conflict, and supports informed decision-making aligned with the client’s wishes.

Choice C rationale: Witnesses are typically required, but a partner’s presence is not legally mandated unless designated as a healthcare proxy.

Choice D rationale: Notarization is not universally required; validity depends on state laws, and many jurisdictions accept signed and witnessed documents without attorney involvement.