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
: "This test will detect the presence of Rh-positive antibodies in your blood." The indirect Coombs' test is a blood test that is used to detect the presence of antibodies against red blood cells in a person's blood. It is commonly used to determine whether a pregnant woman is at risk of hemolytic disease of the newborn (HDN), a condition in which the mother's antibodies attack the red blood cells of the fetus.
Choice A is incorrect because the amount of amniotic fluid around the fetus is measured by an amniocentesis, not a Coombs' test. Choice B is incorrect because ultrasound studies blood flow in the fetus and placenta using sound waves, not ultrasound waves. Choice D is incorrect because hypoglycemia after birth is not related to the Coombs' test, but may be related to other tests, such as a blood glucose test.
Correct Answer is D
Explanation
A. Initiate oxytocin via continuous IV infusion: Oxytocin stimulates uterine contractions, which would increase pressure on the umbilical cord, further compromising fetal oxygenation. This action is contraindicated in the presence of a prolapsed cord.
B. Place the client in the left-lateral position: Although the left-lateral position improves uteroplacental perfusion, it does not relieve pressure on the prolapsed cord. Instead, the nurse should position the client in a knee-chest or Trendelenburg position to reduce cord compression.
C. Request that the provider insert an intrauterine pressure catheter: Intrauterine pressure catheters are contraindicated in cases of umbilical cord prolapse as they can worsen cord compression and fetal hypoxia.
D. Exert continuous upward pressure on the presenting part: This action helps relieve pressure on the umbilical cord, improving blood flow and oxygen supply to the fetus. The nurse should maintain this position while simultaneously calling for immediate assistance and preparing the client for an emergency cesarean delivery.
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