The nurse is orienting a new graduate nurse to the Labor and Birth unit. Which statement indicates that teaching has been effective? "When a client arrives in labor:
1. "A urine specimen is obtained by catheter to check for protein and ketones."
2. "She will be positioned supine to facilitate a normal blood pressure."
3. "Her prenatal record is reviewed for indications of domestic abuse."
4. "A vaginal exam is performed if delivery appears to be imminent."
4
Rationale:
1. A midstream clean-catch specimen is obtained to assess for proteinuria and ketonuria.
2. Supine position predisposes the client to supine hypotension syndrome; side-lying is preferred.
3. Domestic abuse is not the sole reason the prenatal record is examined; any complications of pregnancy are noted.
4. Unless delivery seems imminent because the client is bearing down or contractions are very close and strong, the vaginal exam is performed after the vital signs are obtained.
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