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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Fortified soy milk: Fortified soy milk is a good source of vitamin B12, which is important, especially for individuals following a vegan diet. Vitamin B12 is primarily found in animal products, so those on a vegan diet need to obtain it through fortified foods or supplements.

B. Brown rice: Brown rice is not a significant source of vitamin B12. While it contains other B vitamins, it lacks B12, which is vital for neurological health and the production of red blood cells.

C. Raw carrots: Carrots do not contain vitamin B12. They are rich in beta-carotene (a precursor to vitamin A) and provide other vitamins and minerals, but they are not a source of B12.

D. Fresh citrus fruits: Citrus fruits, like oranges and grapefruits, are good sources of vitamin C, but they do not contain vitamin B12. Vitamin C is important for the absorption of non-heme iron, which is found in plant-based foods, but it does not provide B12.

A. Administer oxygen via a face mask B. Decrease the rate of IV fluids C. perform fetal scalp stimulation D. Elevate the client’s head

Correct Answer is A

Explanation

A. Administer oxygen via a face mask: This is the correct answer. Administering oxygen helps improve oxygenation to the fetus and is a standard intervention for late decelerations.

B. Decrease the rate of IV fluids: Decreasing IV fluids is not typically the first intervention for late decelerations. The primary goal is to improve oxygenation to the fetus, and increasing or maintaining maternal blood volume is important.

C. Perform fetal scalp stimulation: Fetal scalp stimulation is not the first-line intervention for late decelerations. It is more commonly used for assessing fetal well-being and responsiveness during the labor process.

D. Elevate the client’s head: Elevation of the client's head is not the recommended position for addressing late decelerations. Placing the client in a side-lying position is more appropriate to relieve pressure on the vena cava.

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A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

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