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","F"]

Explanation

In the context of a client at 32 weeks of gestation with complete placenta previa, the following assessment findings require immediate follow-up:

A. Fetal heart rate:

Explanation: An elevated fetal heart rate (174/min) may be indicative of fetal distress. This finding requires immediate follow-up to assess the well-being of the fetus.

F. Vaginal bleeding:

Explanation: A moderate amount of bright red vaginal bleeding is a concerning sign, especially in the context of complete placenta previa. It indicates active bleeding, and immediate follow-up is necessary to assess the severity of the situation and the well-being of both the mother and the fetus.

C & D. Hemoglobin (Hgb) and Hematocrit (Hct):

Explanation: Hemoglobin and hematocrit levels are important indicators of blood loss. Given the vaginal bleeding, these values need immediate follow-up to assess the extent of maternal blood loss and the potential need for blood transfusion.

The following assessment findings do not require immediate follow-up in the given context:

B. Fundal height:

Explanation: Fundal height (33cm) is typically measured to assess fetal growth. While it's important to monitor, it may not be an immediate concern unless there are other signs of fetal distress.

E. Platelet count:

Explanation: While platelet count is important, it may not require immediate follow-up unless there is evidence of severe bleeding and a potential risk of disseminated intravascular coagulation (DIC). In this scenario, attention to Hgb and Hct is more urgent.

G & H. White Blood Cell (WBC) count and Red Blood Cell (RBC) count:

Explanation: WBC count and RBC count may be monitored but do not require immediate follow-up unless there are signs of infection or other complications not evident in the given information.

A. Place the client in a semi-Fowler's position for the after administration B. Allow the medication to reach room temperature prior to administration C. instruct the client to avoid urinary elimination until after administration D. Verify that informed consent is obtained prior to administration

Correct Answer is D

Explanation

A. Place the client in a semi-Fowler's position for the after administration: The position of the client during or after administration of dinoprostone (a prostaglandin used for cervical ripening and labor induction) is not typically specified as semi-Fowler's position. The provider may have preferences regarding the positioning, but this is not a general guideline.

B. Allow the medication to reach room temperature prior to administration: There is no specific requirement to allow dinoprostone to reach room temperature before administration. It is typically administered according to the manufacturer's guidelines and the provider's instructions.

C. Instruct the client to avoid urinary elimination until after administration: There is no need to restrict urinary elimination before or after the administration of dinoprostone. In fact, encouraging the client to empty their bladder before administration is often recommended to improve comfort.

D. Verify that informed consent is obtained prior to administration: This is a critical action. Before administering any medication or procedure, the nurse should ensure that the client has provided informed consent. This involves explaining the purpose, risks, benefits, and alternatives of the procedure or medication, and obtaining the client's voluntary agreement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 32 weeks of gestation and has complete placenta previa Exhibits Which of the following assessment findings requires immediate follow-up) Select all that apply

Correct Answer is ["A","F"]

Explanation

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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