A nurse is caring for a client who is receiving oxytocin and notes that the electronic fetal monitor shows persistent late decelerations. Which of the following actions should the nurse take?

Rationale:

A. “I should advise a client about what I feel to be his best health care decision.": Advocacy involves supporting the client’s choices and rights, not imposing the nurse’s personal opinions. Advising based on personal beliefs undermines the client’s autonomy and is not consistent with professional advocacy.

B. "I should not advocate for a client unless he is able to ask me himself.": Client advocacy includes speaking up on behalf of clients who cannot voice their own needs, such as those who are incapacitated or vulnerable. Waiting for the client to ask would neglect the nurse’s responsibility to protect and support the client.

C. “I will intervene if there is a conflict between a client and his provider.": Advocacy involves intervening when a client’s rights, preferences, or safety are at risk, including resolving conflicts with providers. This demonstrates understanding of the nurse’s role in ensuring the client’s voice is heard and needs are met.

D. “I will inform a client that his family should help make his health care decisions.": While family input can be important, the client’s autonomy takes priority. Encouraging family decision-making over the client’s choices does not reflect proper advocacy and may compromise the client’s rights.

Rationale:

A. "Why did you start drinking alcohol?": This question explores motivations or personal history but is not part of the standardized Alcohol Use Disorders Identification Test (AUDIT). The AUDIT focuses on quantity, frequency, and consequences of alcohol use rather than reasons for drinking.

B. "Does anyone else in your family have a drinking problem?": Family history of alcohol use may be relevant for overall assessment but is not included in the AUDIT, which is designed to screen the client’s own drinking behaviors and risks.

C. "How old were you when you started to drink alcohol?": Age of initiation provides background information but is not a question within the AUDIT. The test is concerned with current patterns and consequences of alcohol consumption.

D. "How often do you drink alcohol?": This question is a standard component of the AUDIT and assesses the frequency of alcohol consumption. It helps identify patterns of use and potential risk for alcohol-related problems, making it appropriate for inclusion in the screening.