Level: Clinical
Difficulty: Medium
Subtopic: Fetal monitoring
NCLEX: A 29-year-old client in labor and delivery is being evaluated for labor with external fetal monitoring. Assessmen…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 29-year-old client in labor and delivery is being evaluated for labor with external fetal monitoring. Assessment data include the client reports rectal pressure and an urge to push during active labor. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. SBAR format with specific objective findings, current status, and a clear recommendation.
B. "The client is doing fine; no issues to report."
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
B. "The client is doing fine; no issues to report."
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
Rationale
Correct answer: A. SBAR format with specific objective findings, current status, and a clear recommendation.
Rationale: Handoff and escalation require concise, objective communication such as SBAR with current assessment data.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Handoff and escalation require concise, objective communication such as SBAR with current assessment data.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.