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.
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Related Questions
Correct Answer is D
Explanation
This is the only option that is true and relevant to maternal cytomegalovirus infection. CMV can be transmitted from the newborn to the mother or other caregivers through contact with the saliva and urine of the newborn, which may contain high amounts of the virus. Therefore, it is important to practice good hygiene and avoid contact with these body fluids when caring for a newborn with congenital CMV.
a) This infection does not require that airborne precautions be initiated for the newborn. Airborne precautions are used to prevent the spread of infections that are transmitted by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, measles, or chickenpox. CMV is not transmitted by airborne route, and standard precautions are sufficient to prevent exposure to blood or body fluids that may contain CMV
b) Mothers will not receive prophylactic treatment with acyclovir prior to delivery. Acyclovir is an antiviral medication that is used to treat herpes simplex virus (HSV) infections, such as cold sores, genital herpes, or neonatal herpes. It has no effect on CMV infection, and it is not recommended for pregnant women or newborns with CMV.
c) Lesions are not visible on the mother's genitals. Lesions are a sign of HSV infection, not CMV infection. HSV can cause painful blisters or ulcers on the mouth or genitals, and it can be transmitted to the newborn during delivery. CMV does not cause any visible symptoms on the mother's genitals, and it can be transmitted to the newborn during pregnancy, delivery, or breastfeeding.
Correct Answer is C
Explanation
A client who has had two prior cesarean births is at an increased risk for uterine rupture during labor. Uterine rupture is a serious complication in which there is a complete or partial tear in the uterine wall, potentially leading to significant maternal and fetal morbidity or mortality.
The risk of uterine rupture increases with each prior cesarean birth due to the presence of a scar on the uterus. The scar tissue is weaker than the normal uterine tissue and can potentially rupture during contractions and labor. The risk of uterine rupture is particularly high if the client attempts a vaginal birth after cesarean (VBAC).
Option a) Precipitous labor refers to an extremely fast labor that lasts less than three hours from the onset of contractions to birth. While clients with prior cesarean births may be at increased risk for certain complications, such as uterine rupture, it does not necessarily increase the risk of precipitous labor.
Option b) Abruptio placentae is the premature separation of the placenta from the uterine wall before the birth of the baby. While it is a potential complication during pregnancy, it is not directly associated with prior cesarean births.
Option d) Failure to progress refers to a lack of cervical dilation or descent of the baby during labor. While prior cesarean births can increase the risk of certain labor complications, such as uterine rupture, they do not necessarily increase the risk of failure to progress.
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