A nurse is assisting in evaluating a client's progress during labor.
Click to highlight the client findings that indicate the labor is progressing as expected. To deselect a finding, click on the finding again.
Nurses' Notes
1615:
Client is in the partial sitting position and is instructed to bear down during uterine contraction. Client reports the urge to defecate. There is increased bloody show and the cervix is 10 cm dilated. Contractions 5 min apart. Contractions strong on palpation.
Vital Signs
1615:
Temperature 39.1° C (102.4" F)
Respiratory rate 20/min
Heart rate 110/min
Blood pressure 100/74 mm Hg
Oxygen saturation 96%
Client reports the urge to defecate
There is increased bloody show
cervix is 10 cm dilated
Contractions strong on palpation
Temperature 39.1° C (102.4" F)
Heart rate 110/min
The Correct Answer is ["A","B","C","D"]
Rationale for Correct Options:
- Urge to defecate occurs as the fetal head descends further into the birth canal, putting pressure on the rectum and perineum. This is a common sign of the second stage of labor, indicating that the client is nearing delivery.
- Increased bloody show results from cervical dilation and effacement as the capillaries in the cervix rupture. A greater amount of blood-tinged mucus is expected as labor progresses, particularly in the transition phase and early second stage.
- Cervix 10 cm dilated confirms that the client has reached full cervical dilation, which is required for the second stage of labor to begin. Complete dilation allows for the passage of the fetus through the birth canal.
- Contractions strong on palpation indicate effective uterine activity, which is necessary for fetal descent and expulsion. Strong contractions help in moving the baby downward and increasing pressure on the cervix.
Rationale for Incorrect Options:
- A heart rate of 110/min is elevated compared to the client’s earlier readings (90/min at 0830, 110/min at 0845) and may indicate maternal stress or exertion from labor pain. While mild increases in maternal heart rate are expected during labor, tachycardia above 110/min warrants further evaluation, particularly in the presence of fever.
- Temperature of 39.1°C (102.4°F). This temperature is abnormally high and suggests infection, such as chorioamnionitis, especially considering the prolonged rupture of membranes since 1900 the previous night. Normal maternal temperature may rise slightly during labor due to exertion, but fever above 38°C (100.4°F) is concerning and requires medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Abnormal Involuntary Movement Scale. The Abnormal Involuntary Movement Scale (AIMS) is a validated tool specifically designed to assess and identify tardive dyskinesia in clients taking antipsychotic medications. The AIMS evaluates the presence, frequency, and severity of involuntary movements, providing a structured approach for monitoring and documenting these symptoms over time.
B. Brief Psychiatric Rating Scale. The Brief Psychiatric Rating Scale (BPRS) is utilized to assess a range of psychiatric symptoms, including depression, anxiety, and psychosis. However, it does not specifically address the assessment of abnormal involuntary movements associated with tardive dyskinesia. Therefore, while it is useful for general psychiatric evaluation, it is not appropriate for identifying tardive dyskinesia.
C. Patient Health Questionnaire-9. The Patient Health Questionnaire-9 (PHQ-9) is a widely used screening tool for assessing the severity of depression. It focuses on mood-related symptoms and does not evaluate movement disorders or side effects of antipsychotic medications. As such, it is not relevant for identifying tardive dyskinesia.
D. Mental Status Examination. The Mental Status Examination (MSE) provides a comprehensive assessment of a client’s cognitive and emotional state, covering areas such as appearance, behavior, thought processes, and mood. While the MSE is valuable for overall psychiatric evaluation, it does not specifically assess for tardive dyskinesia or abnormal involuntary movements, making it unsuitable for this purpose.
Correct Answer is A
Explanation
A. "Establish a daily exercise routine." Regular physical activity helps regulate the sleep-wake cycle and promotes deeper sleep. Exercising earlier in the day enhances sleep quality, but vigorous exercise close to bedtime should be avoided as it can be stimulating.
B. "Keep the television volume low while you are trying to fall asleep." Watching television before bed can interfere with melatonin production due to blue light exposure, making it harder to fall asleep. A dark, quiet environment is recommended for better sleep.
C. "Remain in bed until you fall asleep." Staying in bed while struggling to sleep can reinforce insomnia. It is recommended to get out of bed and engage in a relaxing activity if unable to sleep within 20 minutes, then return when drowsy.
D. "Sleep longer hours on the weekend." Sleeping in on weekends disrupts the body's internal clock and can worsen sleep difficulties. Maintaining a consistent sleep schedule, even on weekends, helps regulate circadian rhythms and improve sleep quality.
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