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A nurse is assisting in evaluating a client's progress during labor.

Exhibits

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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "I can stop giving my child this medication if he is taking a steroid." Montelukast is a leukotriene receptor antagonist used for long-term asthma management and should not be discontinued without consulting a provider. It can be used alongside inhaled corticosteroids for better asthma control.
B. "I will give this medication to my child once daily in the evening." Montelukast is typically administered once daily in the evening because leukotrienes contribute to airway inflammation and bronchoconstriction, which can be more pronounced at night. Evening administration maximizes its effectiveness in preventing asthma symptoms.
C. "It takes 2 months of scheduled use before this medication is effective." Montelukast begins to show effects within a few days to a few weeks of consistent use, not two months. However, it is not a rescue medication and should be taken regularly for long-term asthma control.
D. "I will give this medication to my child every 2 hours if he is wheezing." Montelukast is not a rescue medication and does not provide immediate relief for acute bronchospasms. A short-acting beta-agonist, such as albuterol, should be used for rapid symptom relief during wheezing episodes.

A. Disorientation B. Paresthesias C. Sleep apnea D. Tonic-clonic seizures

Correct Answer is A

Explanation

A. Disorientation. Temporary confusion and disorientation are common immediately after electroconvulsive therapy (ECT). This occurs due to the brief, induced seizure affecting brain activity. Clients may also experience short-term memory impairment, but orientation typically improves within minutes to hours.
B. Paresthesias. Abnormal sensations such as tingling or numbness are not expected effects of ECT. While muscle soreness may occur due to seizure activity, paresthesias are not a typical post-procedure finding.
C. Sleep apnea. ECT does not cause sleep apnea. However, clients with pre-existing sleep apnea may require careful monitoring due to anesthetic agents used during the procedure, which could temporarily depress respiratory function.
D. Tonic-clonic seizures. ECT induces a controlled seizure lasting about 30 to 60 seconds, but spontaneous seizures should not occur afterward. If a client experiences an unprovoked seizure post-ECT, further evaluation is needed to rule out underlying neurological conditions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?

Correct Answer is A

Explanation

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