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    HESI LPN EXIT TEST 11 PROCTORED EXAM

    A client who is in active labor is admitted with her cervix dilated to 3 cm with 50% effacement and the presenting part at 0 stations. An hour later, she tells the practical nurse (PN) that she wants to go to the bathroom to empty her bladder. The nurse examines the client again and determines her vaginal exam is unchanged. Which action should the PN implement?

    Explanation & Rationale

    A. Checking the perineum for changes in "show" or discharge is important for monitoring labor progress, but it does not directly address the client's immediate need to empty her bladder. This action would be more relevant if there were signs of labor progression or complications. B. Reviewing the fetal heart rate pattern is crucial for assessing fetal well-being, but it does not resolve the client's discomfort from a full bladder. While important, it does not address the specific request made by the client. C. Obtain a straight catheter kit to empty her bladder is unnecessary since the client can ambulate and has expressed the desire to void. Catheterization is typically reserved for clients unable to void independently or when the bladder is distended and interfering with labor progression. D. Assist the client up to the bathroom is the correct action. Allowing the client to empty her bladder helps facilitate labor progression, as a full bladder can impede fetal descent. Since the vaginal exam is unchanged and the client is stable, ambulation to the bathroom is safe and appropriate. Additionally, this action supports the client’s autonomy and comfort during labor.

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