A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?
intense contractions lasting 45 to 60 seconds
A sense of excitement and warm, flushed skin
An urge to have a bowel movement during contractions
Progressive sacral discomfort during contractions
The Correct Answer is C
A. Intense contractions lasting 45 to 60 seconds: Intense contractions within a normal duration are typical during the active phase of labor. This finding does not necessarily warrant immediate reassessment but rather ongoing monitoring.
B. A sense of excitement and warm, flushed skin: A sense of excitement and warm, flushed skin may be associated with the transition phase of labor and is not necessarily a cause for immediate concern.
C. An urge to have a bowel movement during contractions: This is the correct answer. The urge to have a bowel movement may indicate fetal descent and the need to assess for full cervical dilation. It could signal the need for imminent delivery, and the nurse should promptly assess the client's cervix and notify the healthcare provider.
D. Progressive sacral discomfort during contractions: Discomfort, including sacral discomfort, is common during labor. Progressive sacral discomfort may be associated with the normal progression of labor and is not a reason for immediate reassessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Painful intercourse: Painful intercourse can have various causes, but it is not typically associated with serious complications related to oral contraceptives. It may be addressed with the healthcare provider during a routine follow-up.
B. Vaginal itching: Vaginal itching may be due to various reasons, including infections, but it is not typically a direct side effect of oral contraceptives. However, if the itching is persistent or severe, the client should report it to the provider for appropriate evaluation.
C. Persistent headaches: Persistent headaches can be a concerning side effect associated with the use of oral contraceptives. It may indicate an increased risk of vascular events, such as stroke or thrombosis. Clients experiencing persistent headaches while on oral contraceptives should report this symptom to the healthcare provider immediately for further evaluation.
D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives, and it is not typically an emergency or a sign of serious complications. However, if the breast tenderness is severe or associated with other concerning symptoms, the client should contact the provider for guidance.
Correct Answer is B
Explanation
A. Firm rigid abdomen: A firm and rigid abdomen is more indicative of uterine hypertonicity or uterine hyperstimulation, which is not typically associated with placenta previa. It may be seen in conditions such as uterine rupture.
B. Painless vaginal bleeding: Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless vaginal bleeding. This bleeding occurs because as the cervix begins to dilate and efface in preparation for labor, blood vessels in the placenta may rupture, causing bleeding. Importantly, this bleeding is typically painless and can be sudden and profuse.
C. Uterine hypertonicity: Uterine hypertonicity refers to excessive, uncoordinated uterine contractions. Placenta previa is not generally associated with uterine hypertonicity; instead, it is more commonly linked with uterine relaxation and potential bleeding during contractions.
D. Persistent headache: A persistent headache is not a typical finding in placenta previa. However, it could be associated with conditions like preeclampsia, which might coexist with placenta previa but is a separate concern.
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