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 B

Explanation

A. The client cleans the perineum with a squeeze bottle after urinating: This action is appropriate for postpartum perineal care. Using a squeeze bottle to cleanse the perineum with warm water after urination helps maintain cleanliness without causing trauma to the area.

B. The client is changing the perineal pad once daily: Changing the perineal pad once daily is not optimal for wound healing. Postpartum perineal wounds require frequent changing of pads to maintain cleanliness, prevent infection, and promote healing.

C. The client is using witch hazel pads on the perineum: Using witch hazel pads is a common practice for postpartum perineal care. Witch hazel has a soothing effect and can help reduce inflammation and discomfort without negatively affecting wound healing.

D. The client's perineal suture line is well-approximated: A well-approximated perineal suture line is a positive finding, indicating that the edges of the wound are properly aligned and closed, which supports the healing process.

A. Cloudy urine B. Fundus at level of umbilicus C. Blood pressure 80/50 mm Hg D. Moderate lochia rubra E. Fundus firm to palpation F. Thready pulse

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Explanation

Cloudy urine:

Interpretation: Sign of potential improvement

Explanation: Cloudy urine is unrelated to the diagnosis of postpartum hemorrhage. However, it may be a sign of dehydration, and if the client is receiving appropriate interventions, improved hydration may lead to clearer urine.

Fundus at the level of the umbilicus:

Interpretation: Sign of potential worsening condition

Explanation: The fundus at the level of the umbilicus suggests that the uterus is not adequately contracting. This finding is a sign of potential worsening condition as the uterus should be contracting and descending in the postpartum period.

Blood pressure 80/50 mm Hg:

Interpretation: Sign of potential worsening condition

Explanation: A significant drop in blood pressure (80/50 mm Hg) is indicative of hypotension, which can be a sign of worsening postpartum hemorrhage. Hypotension requires immediate attention and intervention.

Moderate lochia rubra:

Interpretation: Unrelated to diagnosis

Explanation: Lochia rubra is the normal vaginal discharge after childbirth and is unrelated to the diagnosis of postpartum hemorrhage. It is a normal part of the postpartum recovery process.

Fundus firm to palpation:

Interpretation: Sign of potential improvement

Explanation: A firm fundus to palpation is a positive sign, indicating that the uterus is contracting and the bleeding may be decreasing. This is a sign of potential improvement.

Thready pulse:

Interpretation: Sign of potential worsening condition

Explanation: A thready pulse is indicative of reduced cardiac output, possibly due to significant blood loss. It is a sign of potential worsening condition and requires prompt intervention.

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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 postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?

Correct Answer is B

Explanation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Explanation

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