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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Poor feeding is a common manifestation in newborns of mothers who used methadone during pregnancy.
Choice B rationale:
A weak cry is not specifically associated with methadone use during pregnancy.
Choice C rationale:
An absent Moro reflex is not specifically associated with methadone use during pregnancy.
Choice D rationale:
A respiratory rate of 30/min is within the normal range for a newborn (30-60 breaths per minute) and does not indicate methadone exposure.
Correct Answer is B
Explanation
Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.
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