The nurse continues to care for the client.

Nurses' Notes Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.
CBC and urinalysis collected and sent to lab. Day 1,0930:
Peripheral IV initiated. Provider prescriptions received and implemented. Day 1, 1000:
Client voided and reports pain and dicomfort upon urination. Client states, "I've noticed burning wife I urinate for the past 2 days."

Which of the following actions should the nurse take? Select all that apply.

The correct answer is a. Moving both crutches with the stronger leg forward first.

Rationale for Choice C:

• Proper positioning of the hands on the grips and keeping the elbows slightly flexed helps ensure stability and control while using the crutches.

Rationale for Other Choices:

a.In a three-point gait, the client moves both crutches and the affected leg together, followed by the unaffected leg. The stronger leg does not move forward first.

b. Stepping with the affected leg first when going up stairs: This action is incorrect for the three-point gait. When ascending stairs, the client should move the stronger leg up first, followed by the crutches and the affected leg.

d. Supporting his body weight while leaning on the axillary crutch pads: This action is also correct for general crutch use, but it does not specifically address the weight-bearing restrictions and movement pattern of the three-point gait.

Additional Information:

• Practice and supervision:It's essential for the client to practice the three-point gait under the supervision of a healthcare professional to ensure proper technique and safety.
• Gradual progression:The client should gradually increase their distance and duration of crutch use as their strength and coordination improve.
• Pain management:Adequate pain management is crucial to allow the client to participate in rehabilitation and regain mobility.

Based on the client's sudden right-sided numbness, weakness of the arm and leg, and distinct right-sided facial droop, the nurse should suspect a possible stroke and prioritize immediate interventions. After reporting the findings to the healthcare provider and receiving prescriptions, the nurse should implement the following intervention:

Notify the stroke team to assist with acute assessment and management. A stroke is a medical emergency that requires urgent intervention and specialized care. The stroke team is trained to quickly assess and manage stroke patients, including performing necessary diagnostic tests and initiating appropriate treatment. In this case, a STAT computerized tomography (CT) scan of the head has been ordered, indicating the need to evaluate the client's brain for possible ischemic or hemorrhagic stroke.

While keeping the bed in the lowest position and initiating seizure and fall precautions may be important considerations for stroke patients, notifying the stroke team takes precedence as they are specifically trained to manage acute stroke cases.

Administering aspirin to prevent further clot formation and platelet clumping is not appropriate without further assessment and confirmation of the type of stroke.

Additionally, testing for a swallowing reflex and performing communication deficit assessments can be important components of the overall stroke management plan, but they should be carried out by the stroke team or as directed by the healthcare provider.