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 B
Explanation
Choice A rationale:
Bluish discolouration of the hands and feet in a 4-hour-old newborn is likely due to peripheral cyanosis, which is common in the immediate postpartum period and usually resolves on its own without intervention. It is not the priority finding to report to the provider.
Choice B rationale:
This is the correct answer. Overlapping of the cranial bones in a newborn is a significant finding that should be reported to the provider promptly. It may indicate craniosynostosis, a condition in which the sutures of the skull close too early, potentially affecting brain growth.
Choice C rationale:
Forward and lateral positioning of the ears in a 4-hour-old newborn is a normal finding and does not require immediate reporting to the provider.
Choice D rationale:
Small, distended white sebaceous glands on the face, known as milia, are common in newborns and are not a priority finding to report to the provider. They are benign and usually resolve on their own without treatment.
Correct Answer is C
Explanation
Listeriosis is a foodborne illness that can have severe consequences during pregnancy. To minimize the risk of listeriosis, a pregnant client should avoid certain foods that are more likely to be contaminated with the bacteria Listeria. The correct statement that indicates an understanding of the teaching is:
C) "I can eat grilled chicken on a bun at lunchtime."
Grilled chicken is a safe option, and as long as it's properly cooked, it's a suitable choice during pregnancy. The other options are not recommended during pregnancy:
A) Soft cheeses, like Brie or feta, can carry a risk of Listeria contamination, so they should be avoided.
B) Seafood salad from the grocery store may not be safe as it could contain seafood that's been sitting at improper temperatures, which can increase the risk of foodborne illness.
D) Hot dogs can also be a risk as they are often not served steaming hot, which is necessary to kill any potential Listeria contamination.
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