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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 station. An hour later, she tells the practical nurse (PN) that she wants to go to the bathroom to empty her bladder. The nurse exams the client again and determines her vaginal exam is unchanged. Which action should the PN implement?

    Explanation & Rationale

    A. Allowing the client to go to the bathroom independently may pose a safety risk, particularly if the labor progresses rapidly or if she experiences increased discomfort. B. Assisting the client to the bathroom might not be advisable if she is in active labor, as her condition can change quickly, and she may need immediate access to care. C. Offering the client a bedpan or urinal would allow for bladder emptying but may not address the urgency of her desire to ambulate. D. Encouraging the client to hold off until she is further dilated is appropriate, as a full bladder can impede labor progression and lead to complications. This allows for monitoring and assessment of her condition, ensuring that she remains safe and that labor can continue effectively.

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