A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor?

Rationale:

A. Pupil diameter 6 mm: Dilated pupils may indicate CNS stimulation or sensitivity, but this finding is less immediately life-threatening than significant hypotension. Pupil size should still be monitored, especially for signs of overdose or neurologic changes.

B. Blood pressure 80/40 mm Hg: Severe hypotension is a critical adverse effect of IV morphine that can compromise perfusion to vital organs. It requires immediate attention to prevent shock, making this the highest priority finding to report.

C. Urinary output 120 mL/4 hr: While this output is slightly below normal, it does not yet indicate acute kidney injury. Continued monitoring is warranted, but it is not the most urgent issue compared to hypotension.

D. Bowel movement 5 days ago: Constipation is a common side effect of opioids, but it typically develops gradually and can be managed with bowel protocols. It is not as urgent as hypotension and can be addressed after stabilizing the client.

Rationale:

A. "Check your pulse rate for 30 seconds at different times throughout the day.": Clients with pacemakers should check their pulse daily at the same time and for a full minute to ensure the pacemaker is functioning properly. Shorter durations and inconsistent timing may lead to inaccurate assessments.

B. "Limit strenuous physical activity for 8 weeks.” Limiting physical activity, especially involving the upper body, is essential to allow the pacemaker leads to secure in the myocardium. Strain or vigorous movement during the healing phase can displace the leads or disrupt healing.

C. "Remain at least 3 feet away when watching television”: Modern televisions do not emit electromagnetic interference that would affect pacemaker function. There is no need for such distancing, making this instruction inaccurate and unnecessarily restrictive.

D. "Expect to have intermittent, prolonged hiccups.” Persistent hiccups could indicate pacemaker lead displacement or diaphragmatic stimulation and should be reported immediately. They are not an expected or normal finding after pacemaker implantation.