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. "You can bathe and dress your baby if you'd like to.”. B. "I'm sure you will be able to have another baby when you're ready.”. C. "If you don't hold the baby, it will make letting go much harder.”. D. "You should name the baby so she can have an identity.”.

Correct Answer is A

Explanation

Choice A rationale:
Offering the parents the opportunity to bathe and dress their baby can provide a sense of normalcy and closure.
Choice B rationale:
This statement assumes the client wants to have another baby and that they will be able to do so, which may not be the case.
Choice C rationale:
It’s important to allow the parents to grieve in their own way. Some may find holding the baby helpful, while others may not.
Choice D rationale:
While naming the baby can provide an identity, it should be the parents’ decision.

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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

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Correct Answer is A

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