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. Prepare the client for a chest x-ray to verify catheter placement. A chest x-ray is required after central venous catheter insertion to confirm proper placement before initiating total parenteral nutrition (TPN). Incorrect placement can lead to complications such as pneumothorax, arterial puncture, or catheter malposition, making verification essential for safe administration.
B. Use clean technique when changing the catheter dressing. Central venous catheter dressings require sterile technique, not clean technique, to prevent bloodstream infections. Proper infection control measures, including hand hygiene, chlorhexidine skin antisepsis, and sterile gloves, help minimize the risk of catheter-related bloodstream infections.
C. Verify the amount of TPN solution the client is receiving every 4 hr. TPN is typically monitored continuously, with infusion rates checked at least hourly to ensure proper administration. Regular assessments of fluid balance, glucose levels, and electrolyte status are also necessary to prevent complications such as hyperglycemia or fluid overload.
D. Place the client in Sims' position for catheter insertion. The preferred position for central venous catheter insertion is Trendelenburg or supine, which helps dilate the veins and reduces the risk of air embolism. Sims’ position (lying on the left side with the right knee flexed) is not appropriate for this procedure.
Correct Answer is B
Explanation
A. "Cola soft drink." A standard 240 mL (8 oz) serving of cola contains approximately 20 to 40 mg of caffeine. While this is lower than the caffeine content in coffee or tea, it is still higher than that of hot cocoa.
B. "Hot cocoa." Hot cocoa contains the least amount of caffeine, typically around 5 mg per 240 mL (8 oz). Cocoa naturally contains small amounts of caffeine, but it is significantly lower than in coffee, tea, or soda.
C. "Brewed green tea." A 240 mL (8 oz) serving of brewed green tea contains approximately 30 to 50 mg of caffeine. While green tea has less caffeine than coffee, it still has more than hot cocoa.
D. "Instant coffee." Instant coffee has one of the highest caffeine contents per 240 mL (8 oz), ranging from 60 to 80 mg. This makes it a less suitable choice for someone trying to reduce caffeine intake.
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