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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "You cannot have an amniocentesis until you are at least 35 years of age": This statement is not accurate. While advanced maternal age (35 years or older) is often a factor considered for offering amniocentesis due to the increased risk of chromosomal abnormalities, it is not the only factor. Amniocentesis may be recommended for various medical reasons, such as a history of genetic disorders or abnormal prenatal screening results.
B. "We can schedule the procedure for later today if you'd like": The decision to undergo amniocentesis should not be made lightly, and it is typically based on medical indications or concerns. Immediate scheduling without a medical reason is not appropriate. Informed consent and discussion with the healthcare provider about the risks and benefits of the procedure are essential.
C. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby": Chorionic villus sampling (CVS) is a different prenatal diagnostic procedure used to obtain a small sample of placental tissue for genetic testing. It is not typically used solely for determining the sex of the baby. Amniocentesis is the procedure commonly used for both genetic testing and determining the sex of the fetus.
D. "This procedure determines if your baby has genetic or congenital disorders": This is the most appropriate response. Amniocentesis is a diagnostic procedure that involves the removal of a small amount of amniotic fluid for analysis. It is commonly used to assess the risk of genetic and congenital disorders, including chromosomal abnormalities.
Correct Answer is B
Explanation
A. I will receive a series of three immunizations, and each one will be a month apart: This statement is not accurate for rubella immunization. The MMR vaccine is usually administered as a single injection.
B. I should avoid becoming pregnant for at least 1 month following the immunization
Rubella immunization is typically administered as the measles, mumps, and rubella (MMR) vaccine. The statement indicating understanding reflects awareness of the importance of avoiding pregnancy for a certain period after receiving the rubella immunization due to potential risks to the developing fetus.
C. I should avoid breastfeeding for 2 weeks following the immunization: Breastfeeding is not a contraindication after receiving the rubella immunization. In fact, breastfeeding is generally not affected, and mothers can continue to breastfeed.
D. I will report joint pain that develops after the immunization to my provider immediately: Joint pain is a potential side effect of the rubella vaccine. Reporting joint pain to the provider is essential for monitoring and addressing any adverse reactions.
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