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 B
Explanation
A. Open the dampers of fireplaces. Keeping fireplace dampers open would allow contaminated outdoor air to enter the home, increasing exposure to harmful chemicals. During an outdoor chemical disaster, it is essential to seal the home as much as possible to prevent infiltration of toxic substances.
B. Cover heat registers with plastic and tape. Sealing heat registers helps prevent outside air from circulating into the home through ventilation systems. This precaution reduces exposure to airborne chemicals by limiting pathways for contamination. Creating an airtight environment is a key strategy in shelter-in-place recommendations during chemical disasters.
C. Exit the home as quickly as possible. Evacuating during an outdoor chemical disaster may increase the risk of exposure if toxic fumes are present. Authorities typically advise sheltering in place with sealed windows and doors unless an evacuation order is issued. Leaving should only occur when officials confirm that it is safe.
D. Turn on ceiling fans and air conditioners. Running ventilation systems like fans and air conditioners can draw in outside air, increasing exposure to hazardous chemicals. Instead, all air systems should be turned off to minimize circulation of contaminated air within the home.
Correct Answer is B
Explanation
A. "I should not feed my baby anything for 2 hours prior to an immunization." There are no dietary restrictions before routine infant vaccinations. Feeding is encouraged as usual, and breastfeeding may help soothe the infant after immunization.
B. "My baby will receive the rotavirus immunization orally." The rotavirus vaccine is administered orally as a liquid, not as an injection. This vaccine helps protect against severe diarrheal illness caused by rotavirus.
C. "I should expect my baby to have a high fever for 24 hours after an immunization." Mild fever and irritability are common side effects, but a high fever is not expected. Persistent or severe fever should be reported to a healthcare provider.
D. "My baby will receive three doses of the meningococcal immunization before kindergarten." The meningococcal vaccine is not routinely given in infancy. It is typically administered at 11–12 years of age, with a booster at 16 years, unless the infant is at high risk due to certain medical conditions.
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