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 A
Explanation
The correct answer is choiceA. Continue to monitor the client.
Choice A rationale:
Early decelerations are typically benign and are caused by fetal head compression during contractions.They usually do not require any specific intervention other than continued monitoring to ensure they remain early decelerations and do not progress to more concerning patterns.
Choice B rationale:
Discontinuing oxytocin is not necessary for early decelerations, as they are not indicative of fetal distress.Oxytocin would be discontinued if there were signs of more severe decelerations or other complications.
Choice C rationale:
Assisting the client to lay on her right side is not specifically required for early decelerations.This position change is more commonly used for variable or late decelerations to improve uteroplacental blood flow.
Choice D rationale:
Administering oxygen at 8 L/min per mask is not needed for early decelerations.Oxygen is typically reserved for situations where there is evidence of fetal hypoxia or distress.
Correct Answer is D
Explanation
Choice A rationale:
Betamethasone is a corticosteroid used to enhance lung maturity in preterm infants and has no role in treating uterine atony.
Choice B rationale:
Hydralazine is an antihypertensive medication used to lower blood pressure and is not indicated for the management of uterine atony.
Choice C rationale:
Terbutaline is a tocolytic medication used to relax the uterus and delay preterm labour. It is not used to address uterine atony.
Choice D rationale:
Methylergonovine is a uterotonic medication commonly used to treat uterine atony by causing uterine contractions and controlling postpartum bleeding. It helps the uterus contract and prevents further blood loss.
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.