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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Administer 500 ml lactated Ringer's IV bolus:

This choice may be relevant in the context of postpartum hemorrhage, but the first step should be to assess the client's status, including urinary output. Administering fluids without a clear assessment may not address the underlying cause.

B. Replace the surgical dressing:

Vaginal bleeding after a cesarean birth is unlikely to be addressed by replacing the surgical dressing. This action may not address the root cause of the bleeding, which needs further assessment.

C. Apply an ice pack to the incision site:

Using an ice pack is not the appropriate intervention for postpartum bleeding. Ice is typically used for pain and swelling, not for controlling bleeding.

D. Evaluate urinary output:

This is the correct choice. Evaluating urinary output is crucial to assess the client's overall fluid status and kidney perfusion. In the context of postpartum bleeding, it helps determine if there is hypovolemia or other issues contributing to the bleeding. Adequate urinary output is a positive sign of organ perfusion.

A. Lentils B. Asparagus C. oatmeal D. Cabbage

Correct Answer is A

Explanation

A. Lentils: Lentils are an excellent source of dietary fiber. They provide both soluble and insoluble fiber and are high in protein. One cup of cooked lentils can contain a significant amount of fiber.

B. Asparagus: Asparagus is a nutritious vegetable, but its fiber content is relatively lower compared to lentils. It contains soluble and insoluble fiber, contributing to overall dietary fiber intake.

C. Oatmeal: Oatmeal is a good source of soluble fiber, particularly beta-glucans. While it is a healthy choice for increasing fiber intake, the actual fiber content per cup can vary depending on the type and preparation of oatmeal.

D. Cabbage: Cabbage is a vegetable that contains fiber, but its fiber content per cup is generally lower compared to lentils. It is a good addition to a high-fiber diet but may not provide as much fiber in a single cup serving.

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A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

Nursing Test Bank

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