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 ["A","D","G","H"]
Explanation
In the context of the newborn's information, the nurse should report the following findings to the provider:
A. Coombs test result:
Explanation: The Coombs test checks for the presence of antibodies that can destroy red blood cells. In the absence of information about any specific concern or risk factors, a Coombs test result may not be immediately necessary for a term newborn. The nurse should report this finding to the provider for clarification on why the test was performed.
D. Intake and output:
Explanation: The newborn has voided only once since birth. Infrequent voiding can be a concern, and the nurse should report this to the provider for further evaluation, as adequate urine output is important to assess renal function and hydration status.
G. Mucous membrane assessment:
Explanation: Mucous membrane color and moisture are important indicators of hydration. If there are abnormalities, such as pale or dry mucous membranes, the nurse should report this to the provider for further assessment.
H. Sclera color:
Explanation: The color of the sclera can indicate jaundice in a newborn. If the sclera color appears yellow or jaundiced, the nurse should report this finding to the provider for further evaluation.
The following findings are not typically of immediate concern in the given context:
B. Glucose level:
Explanation: While glucose levels are important in certain situations, there is no information suggesting a need for immediate concern about glucose levels in this case. The nurse can monitor blood glucose levels as part of routine care but does not need to report it without specific concerns.
C. Head assessment finding:
Explanation: The information does not provide details about any abnormal head assessment findings. If there are no specific concerns mentioned, the nurse may not need to report this finding unless there are abnormalities observed during routine assessments.
E. Respiratory rate:
Explanation: The respiratory rate is not highlighted as a concern in the given information. If there are no specific abnormalities or signs of respiratory distress, the nurse may not need to report this finding without additional information.
F. Heart rate:
Explanation: The heart rate is not highlighted as a concern, and a normal Apgar score was noted at 5 minutes. If there are no specific concerns or abnormal findings related to the heart rate, the nurse may not need to report this finding without additional information.
Correct Answer is A
Explanation
A. Lentils: Lentils are an excellent source of dietary fiber. They provide both soluble and insoluble fiber and are high in protein. One cup of cooked lentils can contain a significant amount of fiber.
B. Asparagus: Asparagus is a nutritious vegetable, but its fiber content is relatively lower compared to lentils. It contains soluble and insoluble fiber, contributing to overall dietary fiber intake.
C. Oatmeal: Oatmeal is a good source of soluble fiber, particularly beta-glucans. While it is a healthy choice for increasing fiber intake, the actual fiber content per cup can vary depending on the type and preparation of oatmeal.
D. Cabbage: Cabbage is a vegetable that contains fiber, but its fiber content per cup is generally lower compared to lentils. It is a good addition to a high-fiber diet but may not provide as much fiber in a single cup serving.
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