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 C
Explanation
A. Erythema toxicum: Erythema toxicum is a common and benign rash that appears in the first few days of life. It is characterized by pink or red blotches with a small, pimple-like elevation in the center. It is unrelated to a nuchal cord.
B. Periauricular papillomas: Periauricular papillomas are small skin tags or growths around the external ear. They are not typically associated with a nuchal cord and are unrelated to the newborn's delivery.
C. Facial petechiae: A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck. During delivery, this can lead to pressure on the baby's head and face, resulting in small, pinpoint red or purple spots known as petechiae. These are often seen on the face and neck and are considered a transient and benign finding.
D. Telangiectatic nevi: Telangiectatic nevi, also known as "stork bites" or "angel kisses," are common vascular birthmarks. They are not specifically associated with a nuchal cord but rather represent dilated blood vessels near the surface of the skin.
Correct Answer is D
Explanation
A. Human papillomavirus (HPV): The HPV vaccine is generally not administered during pregnancy. It is recommended for routine vaccination before sexual activity begins to provide protection against certain types of HPV that can lead to cervical cancer and genital warts.
B. Varicella (chickenpox): The varicella vaccine is also typically not administered during pregnancy. If a woman is not immune to varicella and is planning pregnancy, vaccination is recommended before conception.
C. Rubella : The rubella vaccine is crucial for individuals who have not been immunized against rubella during childhood, especially in the context of pregnancy. Rubella (German measles) is a viral infection that can cause serious congenital abnormalities, known as congenital rubella syndrome, if a pregnant woman becomes infected. Administering the rubella vaccine during pregnancy is not appropriate, but vaccination before conception or in the postpartum period is recommended to prevent future rubella infections.
D.The tetanus vaccine is safe to administer during pregnancy, typically given as part of the Tdap (tetanus, diphtheria, and pertussis) vaccine. It is recommended during pregnancy, preferably between 27 and 36 weeks of gestation, to protect the newborn from pertussis.
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