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 C
Explanation
A. Right upper quadrant: This is not the correct location for hearing the fetal heart rate in the LOA position, as it is on the opposite side and higher than expected.
B. Left upper quadrant: The fetal heart rate in the LOA position is heard below, not above, the maternal umbilicus.
C. Left lower quadrant: The PMI of the fetal heart rate is best heard in the left lower quadrant when the fetus is in the left occipitoanterior position, as the fetal back (closest to the heart) is located on the left side and positioned anteriorly.
D. Right lower quadrant: This site is appropriate for a right occipitoanterior (ROA) fetal position, not LOA.
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.
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