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 C
Explanation
A. Administer oxygen via face mask at 10 L/min: While oxygen administration may be necessary for a client experiencing excessive bleeding, the first action should be to assess the extent of blood loss. Administering oxygen is not the priority at this point.
B. Prepare the client to receive plasma expander: Plasma expanders, such as intravenous fluids, may be part of the treatment for postpartum hemorrhage, but the immediate priority is to assess the client's blood loss and determine the need for blood products. Fluid replacement alone may not address the underlying issue.
C. Collect hemoglobin and hematocrit levels: This is the correct first action. Hemoglobin and hematocrit levels provide crucial information about the extent of blood loss and the need for further interventions, such as blood transfusions. This information helps guide the overall management of the client.
D. Insert an indwelling urinary catheter: While assessing urinary output is important, it is not the first priority when a client is saturating perineal pads every 10 to 15 minutes. The immediate concern is to assess and manage the excessive bleeding, and obtaining hemoglobin and hematocrit levels is a crucial step in this process.
Correct Answer is D
Explanation
A. Place the client in a semi-Fowler's position for the after administration: The position of the client during or after administration of dinoprostone (a prostaglandin used for cervical ripening and labor induction) is not typically specified as semi-Fowler's position. The provider may have preferences regarding the positioning, but this is not a general guideline.
B. Allow the medication to reach room temperature prior to administration: There is no specific requirement to allow dinoprostone to reach room temperature before administration. It is typically administered according to the manufacturer's guidelines and the provider's instructions.
C. Instruct the client to avoid urinary elimination until after administration: There is no need to restrict urinary elimination before or after the administration of dinoprostone. In fact, encouraging the client to empty their bladder before administration is often recommended to improve comfort.
D. Verify that informed consent is obtained prior to administration: This is a critical action. Before administering any medication or procedure, the nurse should ensure that the client has provided informed consent. This involves explaining the purpose, risks, benefits, and alternatives of the procedure or medication, and obtaining the client's voluntary agreement.
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