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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?

A.

Intense contractions lasting 45 to 60 seconds.

B.

Progressive sacral discomfort during contractions.

C.

A sense of excitement and warm, flushed skin.

D.

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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Related Questions

Correct Answer is D,C,B,A

Explanation

The correct sequence for suctioning a newborn with a bulb syringe, according to the information provided, is as follows: 1. Compress the bulb syringe (d) to expel the air. 2. Place the bulb syringe in the newborn’s mouth © to suction the mucus. 3. Use the bulb syringe to suction the newborn’s nose (b) after the mouth has been cleared. 4. Assess the newborn for reflex bradycardia (a) following the suctioning. This sequence ensures that the airway is cleared effectively and safely, minimizing the risk of inducing bradycardia by stimulating the vagus nerve during suctioning. Always remember to perform these steps gently and to follow the guidelines and protocols of your healthcare facility.

Correct Answer is C

Explanation

The correct answer is choice C: Verify that informed consent is obtained prior to administration. Choice A rationale: Placing the client in a semi-Fowler’s position is not specifically related to the administration of dinoprostone. This position is often used post-administration to promote comfort and labor progression, but it is not a required action prior to the administration of dinoprostone. Choice B rationale: Instructing the client to avoid urinary elimination until after administration is not necessary. There is no evidence to suggest that retaining urine affects the efficacy or safety of dinoprostone administration. Choice C rationale: Verifying that informed consent is obtained prior to administration is crucial. Dinoprostone, like any medication used to induce labor, carries potential risks and side effects. It is essential that the client is informed about these risks and consents to the procedure before the medication is administered. Choice D rationale: Allowing the medication to reach room temperature prior to administration is not a standard requirement for dinoprostone inserts. Medications have specific storage and administration guidelines that should be followed according to the manufacturer’s instructions and facility protocols.

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