A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station.
Which of the following interventions should the nurse implement?

Choice A rationale

Administering a suppository is considered a medication administration task, which requires a licensed nurse to perform. This task involves critical thinking and a solid understanding of anatomy, physiology, and pharmacology, as well as the potential for adverse reactions. Therefore, this cannot be delegated to an assistive personnel (AP), whose scope of practice does not include medication administration.

Choice B rationale

Providing home care instructions is part of client education, which is a key responsibility of a licensed nurse. This task requires a thorough understanding of the client's condition, treatment plan, and the ability to assess their learning needs. An AP is not trained to assess, plan, or implement teaching plans for clients, so this task is outside their scope of practice.

Choice C rationale

Suctioning a newly inserted tracheostomy is a skilled and invasive procedure that carries a high risk of complications, such as hypoxemia, trauma, or infection. This procedure requires a nurse's professional judgment and a clear understanding of sterile technique. The AP's role is to provide basic care, not to perform such complex and high-risk procedures.

Choice D rationale

Performing rescue breathing, or cardiopulmonary resuscitation (CPR), is an emergency procedure that falls within the scope of an AP's training. All healthcare workers, including APs, are required to have a basic life support certification. In a medical emergency, every staff member is expected to perform basic life-saving measures, such as rescue breathing, to prevent further client harm. *.

Choice A rationale

A tracheostomy tray is used to perform an emergency tracheostomy. This procedure is not a standard requirement for a client with a thoracotomy and chest tube placement, as the primary respiratory intervention is typically managed via the chest tube and other supportive measures.

Choice B rationale

Montgomery straps are used to secure dressings that require frequent changes, preventing skin irritation from repeated tape removal. They are useful for abdominal wounds or other high-drainage sites but are not a specific or essential piece of equipment for a chest tube.

Choice C rationale

Wire cutters are used to cut stainless steel wires that may be used to secure the sternum after cardiac surgery. A thoracotomy is an incision into the chest wall to access the thoracic cavity; it does not involve sternal wiring.

Choice D rationale

A padded clamp is an essential piece of equipment at the bedside for a client with a chest tube. In the event of a chest tube dislodgement or if the drainage system needs to be changed, the clamp is used to temporarily occlude the tube to prevent a pneumothorax. .