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 C
Explanation
The correct answer is Choice C.
Choice A rationale: Bluish discoloration of the hands and feet (acrocyanosis) is common in newborns and usually resolves within the first few days of life. It is not typically a priority unless it persists or is accompanied by other signs of distress.
Choice B rationale: Overlapping of the cranial bones (craniosynostosis) requires monitoring but is not an immediate priority unless there are signs of increased intracranial pressure.
Choice C rationale: Forward and lateral positioning of the ears can be indicative of certain genetic conditions, such as Down syndrome. This finding is significant as it can signal the need for further evaluation and intervention to address any associated health concerns.
Choice D rationale: Small, distended white sebaceous glands on the face (milia) are common in newborns and resolve on their own without intervention.
Correct Answer is D
Explanation
The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”
Choice A rationale:
The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.
Choice B rationale:
An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.
Choice C rationale:
Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.
Choice D rationale:
Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.