A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?
An urge to have a bowel movement during contractions
A sense of excitement and warm, flushed skin
Progressive sacral discomfort during contractions
Intense contractions lasting 45 to 60 seconds
The Correct Answer is A
A client who is in labor and reports an urge to have a bowel movement during contractions may be experiencing the transition phase of labor, which is the last and most intense part of the first stage of labor¹². The transition phase occurs when the cervix dilates from 8 to 10 cm and the baby descends into the birth canal¹². The pressure of the baby's head on the rectum can cause a sensation of needing to defecate¹². The transition phase can last from 15 minutes to an hour or more, and it can be accompanied by other signs, such as strong, regular, and painful contractions lasting 60 to 90 seconds; increased bloody show; nausea and vomiting; shaking and shivering; and emotional changes such as irritability, anxiety, or excitement¹²³.
The nurse should reassess the client who reports an urge to have a bowel movement during contractions because this may indicate that the client is close to delivering the baby and needs to be prepared for the second stage of labor, which involves pushing and giving birth¹². The nurse should check the client's cervical dilation, fetal heart rate, and maternal vital signs, and notify the provider if the client is fully dilated or shows signs of fetal or maternal distress¹². The nurse should also support the client's coping strategies, such as breathing techniques, relaxation methods, or pain relief options, and encourage the client not to push until instructed by the provider¹².
b) A sense of excitement and warm, flushed skin are not signs that require reassessment by the nurse. These are normal emotional and physiological responses to labor that reflect increased adrenaline levels and blood flow¹⁴. They do not indicate any complications or imminent delivery.
c) Progressive sacral discomfort during contractions is not a sign that requires reassessment by the nurse. This is a common symptom of labor that results from the pressure of the baby's head on the sacrum and nerves in the lower back¹⁴. It does not indicate any problems or imminent delivery.
d) Intense contractions lasting 45 to 60 seconds are not signs that require reassessment by the nurse. These are typical characteristics of active labor contractions, which occur when the cervix dilates from 4 to 8 cm¹⁴. They do not indicate any complications or imminent delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Breast development is a normal part of fetal and neonatal growth. It occurs in stages, starting before birth and continuing during puberty and adulthood. Breast development is influenced by hormones, such as estrogen and progesterone, that are produced by the ovaries or the placenta¹².
Breast development in newborns can vary depending on the gestational age, sex, weight, and exposure to maternal hormones. Some newborns may have palpable breast tissue at birth, while others may develop it later in the first weeks of life. Some newborns may also secrete milk from their breasts, which is called witch's milk or neonatal galactorrhea. This is a harmless and temporary phenomenon that usually resolves within a few weeks without treatment³⁴.
The degree of breast development in newborns can be assessed by using a scoring system that ranges from 0 to 5, based on the size of the areola (the dark area around the nipple) and the presence of a bud (a small lump of glandular tissue under the areola). The scoring system is as follows³:
- Score 0: No breast tissue; flat areola with no bud
- Score 1: Breast tissue < 5 mm; flat areola with no bud
- Score 2: Breast tissue 5 to 10 mm; flat areola with no bud
- Score 3: Breast tissue > 10 mm; raised areola with no bud
- Score 4: Breast tissue > 10 mm; raised areola with bud
- Score 5: Breast tissue > 10 mm; raised areola with large bud
The average score for term newborns is 2.5 for girls and 2.0 for boys. The score tends to be higher for heavier babies and lower for lighter babies. The score also tends to be higher for babies who were exposed to higher levels of maternal hormones during pregnancy, such as those whose mothers had diabetes, preeclampsia, or multiple gestation³⁴.
A score of 0 indicates that there is no breast tissue at all, and the areola is flat with no bud. This finding can indicate preterm gestational age, as breast development usually starts before birth and progresses with increasing gestational age. Preterm newborns may have delayed or incomplete breast development due to insufficient exposure to maternal hormones or immature development of their own hormonal system³⁵.
Therefore, the nurse should identify this finding as indicating preterm gestational age and monitor the newborn for any other signs of prematurity, such as low birth weight, small head size, thin skin, low body temperature, respiratory distress, or feeding difficulties. The nurse should also provide appropriate care and support to the newborn and the parents according to the hospital protocol³⁵.
- b) Ambiguous secondary sex characteristics are physical features that do not clearly match the typical male or female pattern, such as genitalia, hair distribution, or voice pitch. They can be caused by genetic disorders, hormonal imbalances, or environmental influences. Ambiguous secondary sex characteristics do not affect breast development in newborns, as breast tissue is present in both sexes and is influenced by maternal hormones rather than sex hormones¹ .
- c) Decreased maternal hormones during pregnancy can affect breast development in newborns, but not in the way described. Decreased maternal hormones during pregnancy can cause lower breast scores in newborns, as they may have less stimulation of their breast tissue from the placenta. However, this does not mean that they have no breast tissue at all or a flat areola with no bud. They may still have some degree of breast development depending on their gestational age, sex, weight, and exposure to their own hormones³⁴.
- d) Congenital anomaly is a term that refers to any structural or functional abnormality that is present at birth. Congenital anomalies can affect any part of the body and can have various causes, such as genetic mutations, chromosomal abnormalities, infections, drugs, or environmental factors. Congenital anomalies can affect breast development in newborns, but not in the way described. Congenital anomalies that affect breast development in newborns usually cause abnormal or absent nipples or breasts, such as nipple hypoplasia (underdeveloped nipples), athelia (absence of nipples), amastia (absence of breasts), or polymastia (extra breasts). These anomalies do not cause a flat areola with no bud .
Correct Answer is C
Explanation
Ultrasonography is a diagnostic imaging technique that uses high-frequency sound waves to create images of the internal structures of the body. It is a safe and noninvasive method that can provide valuable information about the pregnancy, such as the number, size, location, and health of the fetus(es), the placenta, the amniotic fluid, and the uterus.
Ultrasonography can be performed at any time during pregnancy, but it is especially useful in the first trimester (the first 12 weeks of pregnancy) for several reasons, such as:
- To confirm the pregnancy and rule out ectopic pregnancy (a pregnancy that occurs outside the uterus) or molar pregnancy (a pregnancy that develops into an abnormal mass of tissue)
- To determine gestational age (the length of time since the first day of the last menstrual period) and estimate due date (the expected date of delivery)
- To screen for chromosomal abnormalities (such as Down syndrome) or structural defects (such as spina bifida) in the fetus
- To identify multiple gestations (such as twins or triplets) or complications (such as miscarriage or
bleeding)
One of the main uses of ultrasonography in the first trimester is to determine gestational age. This is important because it can affect many aspects of prenatal care and delivery, such as:
- The timing and accuracy of other tests and procedures
- The monitoring and evaluation of fetal growth and development
- The identification and management of potential problems or complications
- The planning and preparation for labor and delivery
Gestational age can be determined by measuring the crown-rump length (CRL) of the fetus, which is the distance from the top of the head to the bottom of the spine. The CRL can be measured by using a transvaginal ultrasound (an ultrasound probe that is inserted into the vagina) or a transabdominal ultrasound (an ultrasound probe that is moved over the abdomen). The CRL can be compared to a standard growth chart to estimate gestational age. The CRL measurement is most accurate between 7 and 13 weeks of pregnancy .
Therefore, the newly licensed nurse who says that ultrasound is used to determine gestational age in the first trimester indicates an understanding of the teaching.
The other statements show a lack of knowledge or misunderstanding of the uses of ultrasonography in the first trimester:
- a) "Ultrasound is used to observe for placental maturity in the first trimester." This is not correct because placental maturity is not assessed in the first trimester. Placental maturity refers to the changes that occur in the placenta as it ages and prepares for delivery. Placental maturity can be evaluated by using a grading system that ranges from 0 to 3, based on the appearance of calcifications (deposits of calcium) in the placenta. Placental maturity can be assessed by using a transabdominal ultrasound in the third trimester (after 28 weeks of pregnancy).
- b) "Ultrasound is used to detect intrauterine growth restriction in the first trimester." This is not correct because intrauterine growth restriction (IUGR) is not detected in the first trimester. IUGR is a condition in which the fetus does not grow as expected and has a low birth weight for its gestational age. IUGR can be caused by various factors, such as placental insufficiency, maternal malnutrition, infection, or chronic disease. IUGR can affect fetal development and increase the risk of complications, such as hypoxia, hypoglycemia, or stillbirth. IUGR can be diagnosed by measuring fetal growth parameters, such as abdominal circumference, head circumference, femur length, and estimated fetal weight. These measurements can be obtained by using a transabdominal ultrasound in the second or third trimester (after 20 weeks of pregnancy).
- d) "Ultrasound is used to perform a biophysical profile in the first trimester." This is not correct because a biophysical profile (BPP) is not performed in the first trimester. A BPP is a test that evaluates fetal well-being by assessing five parameters: fetal movement, fetal tone, fetal breathing, amniotic fluid volume, and fetal heart rate. A BPP can help detect fetal distress or hypoxia and guide management decisions. A BPP can be performed by using a combination of transabdominal ultrasound and nonstress test (NST) in the third trimester (after 32 weeks of pregnancy).
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