A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?
Intense contractions lasting 45 to 60 seconds.
Progressive sacral discomfort during contractions.
A sense of excitement and warm, flushed skin.
An urge to have a bowel movement during contractions.
The Correct Answer is D
Choice A rationale:
Intense contractions lasting 45 to 60 seconds are normal during labour and indicate effective uterine activity. This finding does not warrant immediate reassessment.
Choice B rationale:
Progressive sacral discomfort during contractions can be a normal part of labour as the baby descends into the birth canal. It does not necessarily indicate a need for reassessment.
Choice C rationale:
A sense of excitement and warm, flushed skin can be a common emotional and physiological response during labour, particularly as the woman reaches the final stages of delivery. This finding does not necessarily require immediate reassessment.
Choice D rationale:
"An urge to have a bowel movement during contractions”. is the correct answer because it could be an indication that the client is experiencing the urge to push, which means the baby's head is descending and nearing delivery. The nurse should reassess the client promptly to determine if she is fully dilated and ready to push.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Telangiectatic nevi are commonly known as "stork bites”. or "angel kisses”. and are superficial vascular areas commonly found on the nape of the neck or the eyelids of newborns? These are benign and pose no significant health risks.
Choice B rationale:
Erythema toxicum is a common, benign skin rash that appears in the first few days of life. It presents as small, raised red spots with a surrounding halo and is not related to a nuchal cord.
Choice C rationale:
Periauricular papillomas, also known as "ear tags,”. are small, skin-coloured nodules that can be found near the external ear. They are also benign and unrelated to a nuchal cord.
Choice D rationale:
Facial petechiae are tiny, red or purple pinpoint spots on the skin caused by minor haemorrhages. In newborns, facial petechiae can be associated with a nuchal cord, which is a condition where the umbilical cord is wrapped around the baby's neck during delivery. This condition is relatively common and usually resolves without complications. The nurse should monitor the baby for any signs of distress or complications related to the nuchal cord.
Correct Answer is B
Explanation
Choice A rationale:
Swaddling the baby tightly with his legs extended before laying him down to sleep is not a recommended practice, as it can increase the risk of hip dysplasia. Instead, the baby should be placed on their back in a safe sleep environment.
Choice B rationale:
This statement is correct because monitoring the baby's urinary output is essential in ensuring adequate hydration and proper kidney function. Less than six wet diapers a day could be a sign of dehydration and should be promptly reported to the pediatrician.
Choice C rationale:
It is not necessary to retract the foreskin to clean the baby's penis during each bath. The foreskin should be left alone and not forcibly retracted until it naturally loosens, usually around the age of 3 to 5 years.
Choice D rationale:
Applying triple antibiotic ointment on the baby's umbilical cord is not recommended, as the standard practice is to keep the umbilical cord clean and dry. This helps it to fall off naturally within a week or two after birth, reducing the risk of infection.
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