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. Place a witch hazel pad on the client's perineal pad after each voiding: Witch hazel pads can provide relief from perineal discomfort, but they are typically used in the immediate postpartum period for general comfort rather than specifically for third-degree perineal lacerations.

B. Apply hydrogel pads to the perineum every 4 hr: Hydrogel pads can help soothe and cool the perineal area, providing relief from pain and discomfort. This intervention is appropriate for third-degree perineal lacerations.

C. Prepare the client for a pudendal nerve block: Pudendal nerve blocks are typically used for pain relief during the second stage of labor and delivery. They are not a standard intervention for managing third-degree perineal lacerations postpartum.

D. Encourage the client to apply a warm pack to the perineum for discomfort: While warm packs can provide comfort, they are generally not recommended for third-degree perineal lacerations. Cold packs or hydrogel pads are often more appropriate for reducing swelling and providing relief in this situation.

A. Subcutaneous in the left vastus lateralis B. IM in right deltoid C. IM in left vastus lateralis D. Subcutaneous in the right deltoid

Correct Answer is C

Explanation

A. Subcutaneous in the left vastus lateralis: Phytonadione is usually administered IM, not subcutaneously. The vastus lateralis muscle in the thigh is a common site for IM injections in newborns.

B. IM in the right deltoid: The deltoid muscle in the upper arm is not typically the recommended site for administering medications to newborns. The vastus lateralis muscle in the thigh is preferred for newborn IM injections due to better muscle development and blood flow.

C. IM in the left vastus lateralis: This is the correct option. Phytonadione, or Vitamin K, is routinely given to newborns to prevent vitamin K deficiency bleeding (VKDB). It's administered as an IM injection into the vastus lateralis muscle in the thigh, which is a standard practice for newborn vitamin K administration.

D. Subcutaneous in the right deltoid: Subcutaneous administration in the deltoid is not typically used for newborns, especially for medications like phytonadione that are commonly administered IM.

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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

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