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.
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Related Questions
Correct Answer is D
Explanation
A. This medication increases cardiac output: Magnesium sulfate does not typically increase cardiac output. Its primary role in the context of preeclampsia is to prevent seizures and manage hypertension.
B. This medication stabilizes the fetal heart rate: While magnesium sulfate can have a relaxing effect on the uterus, which might indirectly influence fetal heart rate, its primary purpose in preeclampsia is seizure prevention rather than fetal heart rate stabilization.
C. The medication improves tissue perfusion: Magnesium sulfate primarily functions as an anticonvulsant and tocolytic (relaxes the uterus). While its effects on vasodilation can contribute to improved blood flow, the primary indication in preeclampsia is seizure prevention.
D. The medication prevents seizures
Magnesium sulfate is commonly used in the management of preeclampsia to prevent seizures (eclampsia), a serious complication of the condition. It has anticonvulsant properties and is the primary medication for seizure prophylaxis in pregnant individuals with preeclampsia.
Correct Answer is B
Explanation
Correct Answer: B
B. Administer broad-spectrum antibiotics
Newborns with a leaking myelomeningocele are at a high risk for infection, especially meningitis, due to the exposure of cerebrospinal fluid (CSF). Administering broad-spectrum antibiotics helps reduce the risk of infection until the defect is surgically closed.
Incorrect answers:
A.Monitor the rectal temperature every 4 hr.Taking rectal temperatures is contraindicated in a newborn with a myelomeningocele due to the risk of trauma to the rectum and potential introduction of bacteria near the exposed spinal cord and CSF. Axillary temperatures should be used instead.
C.Prepare for surgical closure after 72 hr.Surgical repair of a myelomeningocele is typically performed within the first 24–48 hours of life to reduce the risk of infection and prevent further nerve damage.
D.Cleanse the site with povidone-iodine. Povidone-iodine is not appropriate for cleansing the exposed myelomeningocele site because it can be too harsh and toxic to neural tissue.
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