The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?

Choice A rationale:

Discuss the character of labor from endogenous vs. exogenous oxytocin. While it is important to educate the client about the difference between endogenous (naturally occurring) and exogenous (administered) oxytocin, this information may not address the client's primary concern. The client is refusing the prescribed oxytocin infusion and wants a "natural" delivery. Therefore, discussing alternative ways to support her birth plan is more pertinent.

Choice B rationale:

Ask the healthcare provider to discuss the issue with the client. Involving the healthcare provider in the discussion is a reasonable step, but it should not be the first action taken. The nurse can initiate a conversation with the client to explore her concerns and preferences before escalating the issue to the healthcare provider.

Choice C rationale:

Discuss alternative ways to support the client's birth plan. This is the correct choice because it directly addresses the client's refusal of the oxytocin infusion and desire for a "natural" delivery. Exploring alternative methods for inducing or facilitating labor in a way that aligns with the client's birth plan is essential.

Choice D rationale:

Explain the indications for induction related to post-term pregnancy. Explaining the indications for induction is important for educating the client about the medical reasons behind the prescribed treatment. However, this information may not immediately address the client's refusal of the oxytocin infusion. The nurse should first explore the client's concerns and preferences regarding her birth plan.

The correct answer is choice C: Instruct the UAP to lower the bed for safety.

Choice C rationale: When bathing a bedfast client, the bed should be in a flat or low position to reduce the risk of the client sliding down, falling, or experiencing discomfort or injury. By instructing the UAP to lower the bed, the PN ensures client safety during the bathing process.

Choice A rationale: Assuming care of the client immediately might be unnecessary. The PN should first address the safety concern and then determine if additional intervention is needed.

Choice B rationale: While supervising the UAP may be appropriate in certain situations, the priority in this case is to address the immediate safety concern by instructing the UAP to lower the bed. The PN can then decide if supervision or assistance is required.

Choice D rationale: Determining if the UAP would like assistance is considerate, but it is not the priority in this situation. Ensuring client safety by lowering the bed should be addressed first. The PN can then assess whether the UAP needs any help or guidance.