A nurse is assisting in evaluating a client's progress during labor.
Click to highlight the client findings that indicate the labor is progressing as expected. To deselect a finding, click on the finding again.
Nurses' Notes
1615:
Client is in the partial sitting position and is instructed to bear down during uterine contraction. Client reports the urge to defecate. There is increased bloody show and the cervix is 10 cm dilated. Contractions 5 min apart. Contractions strong on palpation.
Vital Signs
1615:
Temperature 39.1° C (102.4" F)
Respiratory rate 20/min
Heart rate 110/min
Blood pressure 100/74 mm Hg
Oxygen saturation 96%
Client reports the urge to defecate
There is increased bloody show
cervix is 10 cm dilated
Contractions strong on palpation
Temperature 39.1° C (102.4" F)
Heart rate 110/min
The Correct Answer is ["A","B","C","D"]
Rationale for Correct Options:
- Urge to defecate occurs as the fetal head descends further into the birth canal, putting pressure on the rectum and perineum. This is a common sign of the second stage of labor, indicating that the client is nearing delivery.
- Increased bloody show results from cervical dilation and effacement as the capillaries in the cervix rupture. A greater amount of blood-tinged mucus is expected as labor progresses, particularly in the transition phase and early second stage.
- Cervix 10 cm dilated confirms that the client has reached full cervical dilation, which is required for the second stage of labor to begin. Complete dilation allows for the passage of the fetus through the birth canal.
- Contractions strong on palpation indicate effective uterine activity, which is necessary for fetal descent and expulsion. Strong contractions help in moving the baby downward and increasing pressure on the cervix.
Rationale for Incorrect Options:
- A heart rate of 110/min is elevated compared to the client’s earlier readings (90/min at 0830, 110/min at 0845) and may indicate maternal stress or exertion from labor pain. While mild increases in maternal heart rate are expected during labor, tachycardia above 110/min warrants further evaluation, particularly in the presence of fever.
- Temperature of 39.1°C (102.4°F). This temperature is abnormally high and suggests infection, such as chorioamnionitis, especially considering the prolonged rupture of membranes since 1900 the previous night. Normal maternal temperature may rise slightly during labor due to exertion, but fever above 38°C (100.4°F) is concerning and requires medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I can have a meal up to 2 hours before the procedure." Eating before an intravenous pyelogram (IVP) is not recommended, as fasting is typically required to prevent interference with imaging and reduce the risk of nausea from the contrast dye. Clients are usually instructed to refrain from eating for several hours before the procedure.
B. "I should limit my fluid intake for 2 days after the procedure." Increasing, rather than limiting, fluid intake is advised after the procedure to help flush the contrast dye from the kidneys and reduce the risk of nephrotoxicity. Adequate hydration is essential for kidney function following contrast administration.
C. "I do not need to sign a consent form before this procedure." An IVP involves the injection of contrast dye, which carries risks such as allergic reactions and kidney impairment. Because it is an invasive diagnostic procedure, informed consent is required before proceeding.
D. "I will feel a warming sensation after the injection of the dye." The contrast dye used in an IVP often causes a transient warm or flushed feeling, as well as a metallic taste in the mouth. This is a common and expected reaction, indicating that the client understands the procedure.
Correct Answer is A
Explanation
A. Can be a result of an early bowel obstruction. Hyperactive bowel sounds are characterized by loud, high-pitched, and frequent gurgling or rushing noises. They occur when there is increased intestinal motility, which can be seen in conditions such as gastroenteritis, diarrhea, or the early stages of a mechanical bowel obstruction. As the obstruction progresses, bowel sounds may become hypoactive or absent.
B. No sounds heard after listening for 3 to 5 min. This finding indicates absent bowel sounds, not hyperactive ones. Absent bowel sounds suggest complete bowel obstruction, paralytic ileus, or peritonitis and require immediate medical evaluation.
C. Sounds are soft and at a rate of 1/min. Hypoactive bowel sounds, rather than hyperactive ones, are characterized by infrequent, soft, or sluggish sounds occurring at a rate of less than 5 sounds per minute. Hypoactive bowel sounds are often associated with postoperative recovery, peritonitis, or late-stage bowel obstruction.
D. Indicates decreased motility. Hyperactive bowel sounds indicate increased, not decreased, intestinal motility. Decreased motility is associated with hypoactive or absent bowel sounds, which can occur due to conditions such as ileus, bowel obstruction, or the effects of certain medications, including opioids.
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