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    HESI PN Exit Proctored ExamQuestion 57
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    HESI PN Exit Proctored Exam

    A client who is 39 weeks gestation calls the labor and delivery unit to report that she is experiencing mild, irregular contractions. She tells the practical nurse (PN) that the healthcare provider examined her in the clinic today, and her cervix was 3 cm dilated, with intact membranes, and the presenting part was at -1 station. Which intervention should the PN implement?

    Explanation & Rationale

    The correct answer is choice A: Tell her to empty her bladder and call if she has a bloody show. Choice A rationale: The client is 39 weeks gestation and experiencing mild, irregular contractions. The fact that her cervix is already 3 cm dilated and the presenting part is at -1 station indicates that she is in early labor. Emptying the bladder can help relieve pressure on the cervix and promote progress in labor. Instructing her to call if she has a bloody show is essential because it could indicate that her labor is advancing, and she may need to come to the labor and delivery unit soon. Choice B rationale: Directing her to come to the unit for impending delivery is not appropriate at this stage, as she is only experiencing mild, irregular contractions and is likely in early labor. Coming to the unit too early may lead to unnecessary interventions and discomfort for the client. Choice C rationale: Asking the charge nurse for further instructions is not necessary in this situation. The client's condition is not emergent, and the practical nurse can handle the situation appropriately based on the information provided. Choice D rationale: Encouraging ambulation until the contractions are regular might be beneficial in some cases to promote labor progress. However, given that the client is already 3 cm dilated and experiencing mild, irregular contractions, it's better to address the issue of bladder emptying and potential bloody show.

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