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.

A. Incorrect. Acute glomerulonephritis can cause fluid retention and hypertension, rather than hypotension.

B. Incorrect. Weight gain might occur due to fluid retention rather than weight loss.

C. Incorrect. Decreased urine output, not polyuria, is a common finding in acute glomerulonephritis.

D. Correct. Hematuria (blood in the urine) is a classic sign of acute glomerulonephritis, reflecting inflammation and damage to the glomeruli in the kidneys.

Answer:

1. Review the skill level and qualifications of each AP.

2. Communicate appropriate tasks to the APs with specific expectations.

3. Monitor progress of task completion with each AP.

4. Evaluate the APs' performance of each task.

Explanation:

1. Review the skill level and qualifications of each AP: Before delegating tasks to the assistive personnel (APs), the nurse should assess their individual skills, training, and qualifications to determine their capabilities. This step ensures that tasks are assigned to the APs who are competent and trained to perform them safely and effectively.

2. Communicate appropriate tasks to the APs with specific expectations: The nurse should clearly communicate the tasks to be delegated to the APs, providing specific instructions and expectations regarding how each task should be performed. This step helps prevent misunderstandings and ensures that the APs understand what is expected of them.

3. Monitor progress of task completion with each AP: Once tasks are assigned, the nurse should periodically check on the progress of each AP in completing their assigned tasks. Monitoring helps the nurse ensure that tasks are being performed correctly and in a timely manner.

4. Evaluate the APs' performance of each task: After the tasks are completed, the nurse should evaluate the performance of each AP. This evaluation involves assessing whether the tasks were performed according to the specific expectations communicated earlier and whether there were any issues or deviations during task completion. The evaluation helps identify areas for improvement and provides feedback for the APs to enhance their skills and performance.