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 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.
Correct Answer is A
Explanation
A. The client urinates 30 ml/hr
Effective voiding after the removal of a urinary catheter involves the ability to produce an adequate amount of urine. A urine output of 30 ml per hour is within the normal range, indicating that the client is passing urine consistently, which is a positive sign of bladder function.
B. The uterine fundus is 2 cm above the umbilicus: The position of the uterine fundus is related to postpartum uterine involution and is not a direct indicator of effective voiding. It is more relevant to assessing the progress of the uterus returning to its pre-pregnancy state.
C. The bladder is distended upon palpation: A distended bladder is a sign of urinary retention, not effective voiding. If the bladder is distended, it indicates that the client may not be emptying the bladder properly.
D. The client does not feel the urge to urinate: Lack of urge to urinate could be a sign of urinary retention or impaired bladder function. A normal and healthy bladder function includes the sensation of the urge to void when the bladder is filling.
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