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.
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Correct Answer is A
Explanation
Listeriosis is a foodborne illness that can be very dangerous during pregnancy. It is caused by eating foods contaminated with the bacterium Listeria monocytogenes, which can grow well at refrigerator temperatures. Listeriosis can cause miscarriage, stillbirth, preterm labor, and serious illness or death in newborns. Pregnant women are 10 times more likely than other people to get Listeria infection¹.
To prevent listeriosis, pregnant women should avoid certain types of food that are more likely to be contaminated with Listeria, such as:
- Hot dogs and deli meats, unless they are reheated until steaming hot
- Soft cheeses made from unpasteurized milk, such as feta, brie, camembert, blue-veined cheeses, and
queso fresco
- Refrigerated pâtés or meat spreads
- Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna, or mackerel
- Raw or undercooked meat, poultry, seafood, or eggs
- Unpasteurized milk or dairy products
- Unwashed fruits and vegetables
Grilled chicken on a bun is a safe choice for lunchtime because the chicken is cooked and the bun is not likely to be contaminated with Listeria. However, the other options are not safe for pregnant women because they may contain Listeria or other harmful bacteria. A hot dog at the ballpark may not be reheated enough to kill Listeria. A seafood salad from the grocery store may contain refrigerated smoked seafood or mayonnaise made from raw eggs. Soft cheese is often made from unpasteurized milk and can harbor Listeria.
The other options are incorrect because they may expose the client to Listeria or other harmful bacteria, as I explained in my previous response. Let me summarize the reasons for you:
b) "I can still have a hot dog at the ballpark. This is incorrect because hot dogs and deli meats may contain Listeria unless they are reheated until steaming hot. A hot dog at the ballpark may not be hot enough to kill the bacteria.
c) "I can purchase a seafood salad from the grocery store." This is incorrect because seafood salad may contain refrigerated smoked seafood or mayonnaise made from raw eggs. Refrigerated smoked seafood can harbor Listeria and raw eggs can contain Salmonella or other bacteria that can cause food poisoning.
d) "I can have a mid-day snack with soft cheese.” This is incorrect because soft cheese made from unpasteurized milk can be contaminated with Listeria. Examples of soft cheese are feta, brie, camembert, blue-veined cheeses, and queso fresco.
Correct Answer is B
Explanation
This is the action that the nurse should take after recognizing an early deceleration of the fetal heart rate tracing. Early decelerations are symmetrical decreases and return-to-normal linked to uterine contractions¹. The decrease in heart rate occurs gradually, and the nadir of the deceleration occurs at the same time as the peak of the uterine contraction³. Early decelerations are caused by compression of the fetus's head during a uterine contraction, which can stimulate the vagus nerve and cause a decrease in the fetal heart rate⁴. Early decelerations are nothing to be alarmed about¹. They are considered normal and benign, as they do not affect fetal oxygenation or well-being³. Therefore, the nurse should continue to monitor the client and the fetal heart rate tracing and document the findings.
The other options are not correct because they are not appropriate actions for early decelerations.
a) Assist the client to lay on her right side.
This is not an appropriate action for early decelerations, as they are not caused by maternal position or uteroplacental insufficiency. Changing the maternal position may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.
c) Discontinue the oxytocin.
This is not an appropriate action for early decelerations, as they are not caused by oxytocin administration or uterine hyperstimulation. Oxytocin is a hormone that stimulates uterine contractions and can be used to induce or augment labor. However, excessive or prolonged use of oxytocin can cause uterine fatigue and reduce its ability to contract after delivery, leading to uterine atony and postpartum hemorrhage². Oxytocin can also cause late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.
d) Administer oxygen at 8 L/min per mask.
This is not an appropriate action for early decelerations, as they are not caused by fetal hypoxia or acidosis. Oxygen administration may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.
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