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 C
Explanation
Cytomegalovirus (CMV) is a common virus that belongs to the herpes family. Most people who get infected with CMV have no symptoms or only mild symptoms, such as fever, fatigue, or sore throat. However, CMV can cause serious problems in newborns who are infected before birth or around the time of birth. This is called congenital CMV infection¹.
Congenital CMV infection can affect various organs and systems in the newborn, such as the brain, eyes, liver, spleen, lungs, and blood. Some of the possible signs and symptoms of congenital CMV infection are:
- Low birth weight
- Small head size (microcephaly)
- Enlarged liver and spleen (hepatosplenomegaly)
- Yellow skin and eyes (jaundice)
- Purple skin patches or bleeding spots (petechiae or purpura)
- Pneumonia
- Seizures
- Inflammation of the brain (encephalitis) or eye (retinitis)
One of the most common and serious complications of congenital CMV infection is hearing loss. Hearing loss can affect one or both ears and can range from mild to profound. Hearing loss can be present at birth or develop later in childhood. Hearing loss can affect the child's speech, language, and cognitive development².
Hearing loss due to congenital CMV infection is often progressive, meaning that it can worsen over time. Therefore, newborns who are diagnosed with congenital CMV infection should have regular hearing tests to monitor their hearing status and receive early intervention if needed. Early intervention may include hearing aids, cochlear implants, speech therapy, or sign language².
The other options are not typical signs of congenital CMV infection and have different causes:
a) Macrosomia is a condition in which a newborn has a birth weight above the 90th percentile for their gestational age. It can be caused by maternal diabetes, obesity, genetics, or prolonged pregnancy.
b) Cataracts are cloudy areas in the lens of the eye that impair vision. They can be caused by genetic disorders, infections, trauma, or exposure to certain drugs or radiation.
d) Urinary tract infection is an infection of the bladder, urethra, kidneys, or ureters. It can be caused by
bacteria, viruses, fungi, or parasites.
Correct Answer is A
Explanation
A spontaneous abortion (also called a miscarriage) is the unexpected ending of a pregnancy in the first 20 weeks of gestation. The major symptoms of a spontaneous abortion are abdominal cramps and bleeding from the vagina, sometimes with clots and/or bits of tissue³. A dilated cervix indicates that abortion is inevitable¹. Other symptoms may include low back ache, a decrease in pregnancy symptoms, and leaking amniotic fluid.
The other options are not answers because they are not indicative of an imminent spontaneous abortion.
b. Slight abdominal cramps
Slight abdominal cramps are a common symptom of early pregnancy and do not necessarily mean that a miscarriage is happening. However, if the cramps are severe, persistent, or accompanied by bleeding, then they could be a sign of a problem and should be reported to the provider.
c. Elevated hCG
hCG (human chorionic gonadotropin) is a hormone produced by the placenta during pregnancy. It can be measured in the blood or urine to confirm pregnancy or monitor its progress. Elevated hCG levels are not a sign of a spontaneous abortion, but rather a normal finding in early pregnancy. In fact, low or decreasing hCG levels may indicate a miscarriage or an ectopic pregnancy.
d. Scant bright red spotting
Scant bright red spotting is another common symptom of early pregnancy and does not necessarily mean that a miscarriage is happening. It may be caused by implantation bleeding, cervical irritation, or sexual intercourse. However, if the spotting is heavy, dark, or accompanied by cramps or pain, then it could be a sign of a problem and should be reported to the provider.
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