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 C
Explanation
Choice Arationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.
Choice Brationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.
Correct Answer is B
Explanation
Choice A rationale:
Asking if the partner is pressuring the client to have sex is important, but it’s not the most relevant question when a client requests birth control.
Choice B rationale:
Asking what the client knows about contraception is the most relevant question. It allows the nurse to assess the client’s knowledge and provide appropriate education.
Choice C rationale:
Asking if the client is sure their partner loves them is not relevant to the client’s request for birth control.
Choice D rationale:
Asking why the client is requesting birth control is important, but it’s not as relevant as assessing the client’s knowledge about contraception.
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