A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?
intense contractions lasting 45 to 60 seconds
A sense of excitement and warm, flushed skin
An urge to have a bowel movement during contractions
Progressive sacral discomfort during contractions
The Correct Answer is C
A. Intense contractions lasting 45 to 60 seconds: Intense contractions within a normal duration are typical during the active phase of labor. This finding does not necessarily warrant immediate reassessment but rather ongoing monitoring.
B. A sense of excitement and warm, flushed skin: A sense of excitement and warm, flushed skin may be associated with the transition phase of labor and is not necessarily a cause for immediate concern.
C. An urge to have a bowel movement during contractions: This is the correct answer. The urge to have a bowel movement may indicate fetal descent and the need to assess for full cervical dilation. It could signal the need for imminent delivery, and the nurse should promptly assess the client's cervix and notify the healthcare provider.
D. Progressive sacral discomfort during contractions: Discomfort, including sacral discomfort, is common during labor. Progressive sacral discomfort may be associated with the normal progression of labor and is not a reason for immediate reassessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You can bathe and dress your baby if you'd like to": This statement acknowledges the client's autonomy and offers a sensitive and supportive approach. Allowing the client the option to participate in the care of the baby, such as bathing and dressing, respects the individual grieving process.
B. "I'm sure you will be able to have another baby when you’re ready": While the nurse may want to provide hope for the future, this statement might be perceived as minimizing the client's current grief and loss. It's essential to focus on the present and the client's emotions.
C. "You should name the baby so she can have an identity": Naming the baby is a personal choice, and the nurse should avoid directing the client on what they "should" do. Naming the baby can be a meaningful way for some parents to acknowledge the baby's existence and create memories.
D. "If you don’t hold the baby, it will make letting go much harder": Pressuring the client to hold the baby may not be appropriate, as individuals have different coping mechanisms. Some may find comfort in holding and spending time with the baby, while others may need more time before they are ready.
Correct Answer is A
Explanation
To calculate the estimated date of delivery using Nägele's rule:
Start with the first day of the last menstrual period (LMP).
Add 7 days.
Count back 3 months.
Add 1 year.
The last menstrual period started on June 21.
Adding 7 days to June 21: June 28
Counting back 3 months from June: March 28
Adding 1 year to March: March 28 in the next year
Therefore, the estimated date of delivery using Nägele's rule would be March 28 in the next year.
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