A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?

Intense contractions lasting 45 to 60 seconds.

Progressive sacral discomfort during contractions.

A sense of excitement and warm, flushed skin.

An urge to have a bowel movement during contractions.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Intense contractions lasting 45 to 60 seconds are normal during labour and indicate effective uterine activity. This finding does not warrant immediate reassessment.

Choice B rationale:

Progressive sacral discomfort during contractions can be a normal part of labour as the baby descends into the birth canal. It does not necessarily indicate a need for reassessment.

Choice C rationale:

A sense of excitement and warm, flushed skin can be a common emotional and physiological response during labour, particularly as the woman reaches the final stages of delivery. This finding does not necessarily require immediate reassessment.

Choice D rationale:

"An urge to have a bowel movement during contractions”. is the correct answer because it could be an indication that the client is experiencing the urge to push, which means the baby's head is descending and nearing delivery. The nurse should reassess the client promptly to determine if she is fully dilated and ready to push.

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Correct Answer is B

No explanation

A. Temperature 37.4°C (99.3°F). B. Uterine tenderness. C. WBC Count 9,000/mm. D. Scant lochia.

Correct Answer is B

Explanation

Choice A rationale:

A postpartum temperature of 37.4°C (99.3°F) is within the normal range. Mild temperature elevations can be expected in the immediate postpartum period without indicating infection.

Choice B rationale:

Uterine tenderness is a common finding in endometritis, which is an inflammation or infection of the inner lining of the uterus. The condition can cause pelvic pain and uterine tenderness.

Choice C rationale:

A white blood cell (WBC) count of 9,000/mm³ falls within the normal range for a postpartum client. In endometritis, an elevated WBC count would be expected due to the infection.

Choice D rationale:

Scant lochia (minimal vaginal discharge after childbirth) is a normal finding in the postpartum period and is not associated with endometritis. In endometritis, the lochia may be increased and foul-smelling.

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A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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