A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

Intense contractions lasting 45 to 60 seconds.

An urge to have a bowel movement during contractions.

A sense of excitement and warm, flushed skin.

Progressive sacral discomfort during contractions.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Intense contractions lasting 45 to 60 seconds are normal during labor.
Choice B rationale:
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal, which may require immediate attention.
Choice C rationale:
A sense of excitement and warm, flushed skin are normal emotional and physiological responses during labor.
Choice D rationale:
Progressive sacral discomfort during contractions is a normal part of labor as the baby descends through the birth canal.

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Correct Answer is A

Explanation

Choice A rationale:
Yellowed sclera in a newborn could indicate jaundice, which should be reported to the provider.
Choice B rationale:
Stooling after each breastfeeding is normal for a newborn.
Choice C rationale:
Intermittent crossing of eyes is common in newborns and usually resolves by 3 months of age.
Choice D rationale:
Voiding eight to ten times per day is normal for a newborn.

A. Plan to administer ephedrine IV. B. Assist the client to empty their bladder. C. Assess for the presence of clonus. D. Prepare to initiate cardiopulmonary resuscitation.

Correct Answer is D

Explanation

Choice A rationale:
Administering ephedrine IV is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Ephedrine is typically used to treat hypotension during spinal anesthesia, not amniotic fluid embolism.
Choice B rationale:
Assisting the client to empty their bladder is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. While bladder care is important, it is not the priority in this situation.
Choice C rationale:
Assessing for the presence of clonus is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Clonus is typically assessed in clients with preeclampsia or eclampsia, not amniotic fluid embolism.
Choice D rationale:
Preparing to initiate cardiopulmonary resuscitation is the appropriate action for a client experiencing an amniotic fluid embolism during labor. Amniotic fluid embolism can lead to cardiovascular collapse, therefore, immediate resuscitation measures should be prepared15.

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A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a new parent about findings that require notification of the newborn's provider. Which of the following newborn clinical manifestations should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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