A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?
Progressive sacral discomfort during contractions
Intense contractions lasting 45 to 60 seconds
An urge to have a bowel movement during contractions
A sense of excitement and warm, flushed skin
The Correct Answer is C
A. Discomfort in the lower back (sacral area) is common during labor, particularly during contractions. This is not an unusual finding that would require immediate reassessment.
B. Contractions lasting between 45 to 60 seconds are typical during the active phase of labor. This duration of contractions is expected as labor progresses, and does not require immediate reassessment.
C. This sensation can indicate that the fetus has descended into the birth canal and may be a sign that the client is entering the second stage of labor, or is close to delivery. This requires immediate reassessment by the nurse to check for full cervical dilation and fetal descent.
D. Emotional excitement and changes in skin temperature are typical responses during labor due to the physiological and emotional aspects of childbirth. This does not indicate the need for immediate reassessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This option is incorrect because the development of breast tissue in newborns is not directly related to the mother’s hormone levels during pregnancy. Newborns typically have breast buds regardless of maternal hormone variations.
B. A flat areola with no breast bud is a characteristic finding in preterm newborns. Breast tissue development is one of the physical markers used to assess gestational age, and the lack of a breast bud is an indicator of immaturity, suggesting a preterm gestational age.
C. Ambiguous secondary sex characteristics are not related to the presence or absence of breast buds in newborns. This option focuses on sexual development rather than gestational markers.
D. A flat areola with no breast bud is a normal finding in preterm infants and does not indicate a congenital anomaly. This condition is expected in preterm newborns based on their developmental stage.
Correct Answer is B
Explanation
The correct answer is choice B. Facial petechiae are a clinical finding that can occur in newborns who had a nuchal cord during delivery. The nuchal cord occurs when the umbilical cord becomes wrapped around the fetal neck one or more times. Erythema toxicum is a common, benign rash that appears as small, firm, yellow, or white papules surrounded by a red halo. Periauricular papillomas and telangiectatic nevi are not associated with the nuchal cord.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today