The nurse is in the process of admitting a multiparous woman to labor and delivery from the triage area.
One hour ago her vaginal exam was 5 cm dilated, 50% effaced, 1+ station.
While completing your review of her prenatal record and completing the admission Questionnaire, she tells you she has an urge to have a bowel movement.
The priority nursing intervention is to:
Reassure the client and rapidly complete the admission.
Assist your client to the bathroom to have a bowel movement.
Assess the fetal heart rate and uterine contractions with a routine tracing.
Assess her progress of labor with a vaginal exam as delivery is close.
The Correct Answer is D
Choice A rationale
Reassuring the client and rapidly completing the admission does not address the urgent symptom of an urge to have a bowel movement, which can indicate imminent delivery. Immediate assessment of labor progress is necessary.
Choice B rationale
Assisting the client to the bathroom to have a bowel movement may not be appropriate because the urge to defecate can signify the onset of the second stage of labor (pushing stage). Moving to the bathroom could risk an unattended delivery.
Choice C rationale
Assessing the fetal heart rate and uterine contractions with a routine tracing is important, but it does not directly address the urgent symptom of the urge to have a bowel movement. Vaginal exam takes priority to assess labor progress.
Choice D rationale
Assessing her progress of labor with a vaginal exam is the priority because the urge to have a bowel movement can signify that the baby is descending in the birth canal. This is the most immediate and necessary action to determine if delivery is imminent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
High blood glucose levels in early pregnancy increase the risk of congenital heart defects in the baby.
Choice B rationale
Hip dysplasia is not directly associated with maternal diabetes but can be a congenital condition regardless of maternal glucose control.
Choice C rationale
Necrotizing enterocolitis is more related to prematurity and not directly linked to maternal diabetes.
Choice D rationale
Port wine stains are vascular birthmarks and are not associated with maternal blood glucose levels. .
Correct Answer is D
Explanation
Choice A rationale
Premature rupture of the membranes refers to the breaking of the amniotic sac before labor starts. It is not a definitive indicator of true labor, as contractions and cervical changes need to accompany it to confirm labor onset.
Choice B rationale
Light irregular pattern of contractions is often associated with false labor or Braxton Hicks contractions. True labor contractions are typically regular, progressively stronger, and closer together.
Choice C rationale
3 station of the presenting part refers to the baby's descent into the pelvis. While it indicates labor progression, it is not the most definitive sign of true labor compared to cervical changes.
Choice D rationale
Progressive cervical dilation is the most reliable indicator of true labor. It signifies that the cervix is opening up in response to regular and effective contractions, indicating the body is preparing for childbirth.
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