A nurse is evaluating a client's acceptance of having a new ileostomy.
Which of the following statements by the client indicates acceptance?

The correct answer is Choice D.

Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.

Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.

Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.

Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.

Choice A rationale:

"Apply fundal pressure during contractions." - Applying fundal pressure during contractions is not appropriate during the latent stage of labor. Fundal pressure is typically used during the second stage of labor (active pushing phase) to assist with fetal descent. Using it during the latent stage can be harmful.

Choice B rationale:

"Encourage the client to soak in a hot bath." - Soaking in a hot bath is generally not recommended during labor, especially without specific indications. It is essential to maintain the safety and well-being of both the mother and the baby. Encouraging the client to change positions or use comfort measures like relaxation techniques would be more appropriate.

Choice C rationale:

"Instruct the client to change positions frequently." - This is the correct answer. During the latent stage of labor, encouraging the client to change positions frequently can help promote comfort and optimize fetal positioning. Changing positions can reduce discomfort, enhance uterine contractions, and facilitate the progression of labor.

Choice D rationale:

"Tell the client to push during contractions." - Pushing during contractions is typically reserved for the second stage of labor when the cervix is fully dilated. In the latent stage, the cervix is not fully dilated, and pushing prematurely can be harmful and delay labor progress. It is essential to follow the appropriate guidelines for each stage of labor.