Chapter 01_LO 01_Q01 The Labor and Delivery nurse and a nurse new to the Labor and Delivery unit are admitting a laboring client. The client is making groaning guttural sounds during contractions, and answering questions with one-word answers. The Labor and Delivery nurse simultaneously is quickly setting up the instruments and sterile field for this delivery while asking the admission questions between contractions. The experienced Labor and Delivery nurse has not yet completed a pelvic exam. The nurse new to Labor and Delivery understands that this is an example of: 1. An expert nurse assessing advanced labor and imminent delivery in the client. 2. The correct order of steps when admitting laboring clients. 3. Inconsistencies in an individual nurse’s approach to client care. 4. Advanced nurse practice. Correct answer: 1 Rationale: 1. An expert nurse utilizes multiple aspects of a client’s behavior (including the length of each response to a question, and sounds the patient produces during contractions) in addition to the more objective findings of the pelvic exam (including dilation of the cervix) in the assessment of a laboring client. The expert nurse has identified that the grunting and guttural sounds during contractions are involuntary pushing, and that the client is very close to delivery. 2. Although most nurses have a routine when admitting a client, the order of the steps will vary according to the situation at hand. 3. Changing the order of the steps of admission is not being inconsistent; changing the order of the steps of admission is responsive to the needs of the client at that point in time. 4. Advanced nurse practice describes educational and certification achievement, and is not used to describe the continuum from novice to expert. Cognitive level: Application Category of Client Need: Health Promotion and Maintenance Nursing Process: Assessment
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