A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?
An urge to have a bowel movement during contractions
A sense of excitement and warm, flushed skin
Progressive sacral discomfort during contractions
Intense contractions lasting 45 to 60 seconds
The Correct Answer is A
A client who is in labor and reports an urge to have a bowel movement during contractions may be experiencing the transition phase of labor, which is the last and most intense part of the first stage of labor¹². The transition phase occurs when the cervix dilates from 8 to 10 cm and the baby descends into the birth canal¹². The pressure of the baby's head on the rectum can cause a sensation of needing to defecate¹². The transition phase can last from 15 minutes to an hour or more, and it can be accompanied by other signs, such as strong, regular, and painful contractions lasting 60 to 90 seconds; increased bloody show; nausea and vomiting; shaking and shivering; and emotional changes such as irritability, anxiety, or excitement¹²³.
The nurse should reassess the client who reports an urge to have a bowel movement during contractions because this may indicate that the client is close to delivering the baby and needs to be prepared for the second stage of labor, which involves pushing and giving birth¹². The nurse should check the client's cervical dilation, fetal heart rate, and maternal vital signs, and notify the provider if the client is fully dilated or shows signs of fetal or maternal distress¹². The nurse should also support the client's coping strategies, such as breathing techniques, relaxation methods, or pain relief options, and encourage the client not to push until instructed by the provider¹².
b) A sense of excitement and warm, flushed skin are not signs that require reassessment by the nurse. These are normal emotional and physiological responses to labor that reflect increased adrenaline levels and blood flow¹⁴. They do not indicate any complications or imminent delivery.
c) Progressive sacral discomfort during contractions is not a sign that requires reassessment by the nurse. This is a common symptom of labor that results from the pressure of the baby's head on the sacrum and nerves in the lower back¹⁴. It does not indicate any problems or imminent delivery.
d) Intense contractions lasting 45 to 60 seconds are not signs that require reassessment by the nurse. These are typical characteristics of active labor contractions, which occur when the cervix dilates from 4 to 8 cm¹⁴. They do not indicate any complications or imminent delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A, B, D, C
Explanation
- Compressing the bulb syringe before placing it in the newborn's mouth or nose creates a vacuum that allows the suctioning of the mucus¹².
- Placing the bulb syringe in the newborn's mouth first helps clear the oral airway and prevent aspiration of mucus into the lungs¹². The nozzle of the bulb syringe should be gently inserted into the corner of the mouth, not the center, to avoid stimulating the gag reflex¹².
- Using the bulb syringe to suction the newborns nose helps clear the nasal airway and improve breathing¹². The nozzle of the bulb syringe should be gently inserted into one nostril at a time, and not too far, to avoid injuring the nasal mucosa¹².
- Assessing the newborn for reflex bradycardia helps monitor for any adverse effects of suctioning, such as a decrease in heart rate due to vagal stimulation¹³. Reflex bradycardia can cause hypoxia and acidosis in newborns, and may require oxygen administration or resuscitation³. The normal heart rate for a newborn is 120 to 160 beats per minute³.
Correct Answer is D
Explanation
Preparing a toddler for a new sibling can be challenging, but there are some strategies that can help ease the transition and reduce the risk of jealousy or resentment. One of these strategies is to make any major changes in the toddler's routine or environment well before the baby arrives, such as moving to a new bed, starting preschool, or toilet training. This can help the toddler adjust to the change without feeling displaced or threatened by the baby. It can also prevent the toddler from associating the change with the baby and blaming the baby for it¹².
Moving a toddler to a new bed 2 months before the baby comes home is a good example of this strategy. It gives the toddler enough time to get used to sleeping in a different place and feeling comfortable and secure in it. It also avoids making the toddler feel like they are being kicked out of their bed to make room for the baby. The toddler may even feel proud of having a big-kid bed and being more independent¹².
The other options are not appropriate responses by the nurse because they may have negative effects on the toddler's adjustment to the new sibling:
a) "Let your toddler see you carrying the baby into the home for the first time." This is not a good idea because it may make the toddler feel left out or replaced by the baby. The toddler may not understand why they were not with you when you brought the baby home and may feel hurt or angry. A better option is to have someone else carry the baby into the home while you greet your toddler with a hug and a smile. Then, you can introduce your toddler to their new sibling and involve them in welcoming and caring for the baby¹³.
b) "Avoid bringing your toddler to prenatal visits." This is not a good idea because it may make the toddler feel excluded or curious about what is going on. Bringing your toddler to some of your prenatal visits can help them learn more about the baby and feel more connected to them. You can show your toddler pictures of the baby's development, let them hear the baby's heartbeat, or ask them to help you choose clothes or toys for the baby. However, you should also be prepared for your toddler's possible boredom or impatience during long or boring appointments and bring some snacks or activities to keep them entertained¹⁴.
c) "Require scheduled interactions between the toddler and the baby." This is not a good idea because it may make the toddler feel pressured or resentful toward the baby. Forcing your toddler to interact with the baby when they are not ready or interested can backfire and cause more conflict or distance between them. A better option is to follow your toddler's cues and let them decide how much and when they want to interact with the baby. You can also praise your toddler for any positive interactions they have with the baby, such as giving them a gentle kiss, sharing a toy, or singing a song¹³.
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