A nurse is caring for a client who is receiving IV fluid therapy. For which of the following findings should the nurse monitor as an adverse effect of the IV fluid therapy?

A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.

A. Contraction intensity increased by ambulation. This finding is typical of true labor, as walking or changing positions usually causes contractions to increase in strength, duration, and frequency. In contrast, false labor contractions often subside with rest or activity changes and do not intensify with movement.
B. Slow change in dilation and effacement. Any change in cervical dilation or effacement, even if slow, is more consistent with true labor. False labor does not produce any significant cervical change, and the cervix remains closed or minimally altered with time or contractions.
C. Presence of bloody show. Bloody show is the expulsion of the mucus plug mixed with blood, a common sign of cervical softening and dilation. This is a key indicator of true labor, as it reflects actual physical changes in preparation for delivery.
D. Intermittent painless contractions. These contractions, also called Braxton Hicks contractions, are a hallmark of false labor. They are usually irregular, mild, and do not lead to cervical changes. They often resolve with hydration, rest, or position changes and are considered a normal part of the body's preparation for labor, not the onset of true labor.