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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C: Uterine tenderness. Endometritis is an infection of the endometrial lining of the uterus. Uterine tenderness is a common finding in clients with endometritis.

Choice A, scant lochia, and choice D, WBC count 9,000/mm², are not typical findings in clients with endometritis. Choice B, temperature 37.4° C (99.3° F), is within the normal range and may not be indicative of endometritis.

A. Feed the newborn 5 to 10 min per breast. B. Allow the baby to feed at least every 3 hr. C. Offer the newborn 30 mL (1 oz) of water between feedings. D. Expect two to four wet diapers every 24 hr.

Correct Answer is B

Explanation

The correct answer is choice B, "Allow the baby to feed at least every 3 hr." The nurse should instruct the client who is breastfeeding her newborn to allow the baby to feed at least every 3 hr, which can help to establish an adequate milk supply. The client should also be instructed to feed the newborn on demand, offer both breasts at each feeding, and continue to breastfeed for as long as the baby is interested. The nurse should advise the client to expect at least six to eight wet diapers every 24 hr and monitor the newborn for signs of dehydration, such as a decrease in urine output, dry mucous membranes, or lethargy.

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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 assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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