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.

An urge to have a bowel movement during contractions.

A sense of excitement and warm, flushed skin.

Progressive sacral discomfort during contractions.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Intense contractions lasting 45 to 60 seconds are normal during labor.
Choice B rationale:
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal, which may require immediate attention.
Choice C rationale:
A sense of excitement and warm, flushed skin are normal emotional and physiological responses during labor.
Choice D rationale:
Progressive sacral discomfort during contractions is a normal part of labor as the baby descends through the birth canal.

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Correct Answer is A

Explanation

Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.

A. Give oxytocin 20 units IV bolus. B. Perform a fundal massage. C. Assess for abdominal tenderness. D. Obtain serial hemoglobin and hematocrit.

Correct Answer is D

Explanation

Choice A rationale:
Giving oxytocin 20 units IV bolus is incorrect. Oxytocin is used to stimulate uterine contractions, not to stop bleeding.
Choice B rationale:
Performing a fundal massage is incorrect. This is done to stimulate uterine contractions, not to stop bleeding.
Choice C rationale:
Assessing for abdominal tenderness is incorrect. This is not a priority action when a client is exhibiting a large amount of vaginal bleeding.
Choice D rationale:
Obtaining serial hemoglobin and hematocrit is correct. These lab tests will help determine the extent of blood loss and guide treatment.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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