The nurse is in the process of admitting a multiparous woman to labor and delivery from the triage area.
One hour ago her vaginal exam was 5 cm dilated, 50% effaced, 1+ station.
While completing your review of her prenatal record and completing the admission Questionnaire, she tells you she has an urge to have a bowel movement.
The priority nursing intervention is to:
Reassure the client and rapidly complete the admission.
Assist your client to the bathroom to have a bowel movement.
Assess the fetal heart rate and uterine contractions with a routine tracing.
Assess her progress of labor with a vaginal exam as delivery is close.
The Correct Answer is D
Choice A rationale
Reassuring the client and rapidly completing the admission does not address the urgent symptom of an urge to have a bowel movement, which can indicate imminent delivery. Immediate assessment of labor progress is necessary.
Choice B rationale
Assisting the client to the bathroom to have a bowel movement may not be appropriate because the urge to defecate can signify the onset of the second stage of labor (pushing stage). Moving to the bathroom could risk an unattended delivery.
Choice C rationale
Assessing the fetal heart rate and uterine contractions with a routine tracing is important, but it does not directly address the urgent symptom of the urge to have a bowel movement. Vaginal exam takes priority to assess labor progress.
Choice D rationale
Assessing her progress of labor with a vaginal exam is the priority because the urge to have a bowel movement can signify that the baby is descending in the birth canal. This is the most immediate and necessary action to determine if delivery is imminent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Gestational age helps assess fetal development and potential complications. It is essential information for the provider to determine appropriate care and interventions.
Choice B rationale
Vaginal examination findings provide insight into cervical dilation, effacement, and station, which are critical for monitoring labor progress and making informed decisions about labor management.
Choice C rationale
Uterine contractions are a key indicator of labor progress. The frequency, duration, and intensity of contractions help the provider assess labor progression and plan necessary interventions.
Choice D rationale
Birthing parent's blood pressure is crucial for monitoring maternal well-being, especially in cases of pre-eclampsia or other hypertensive disorders. Elevated blood pressure can indicate complications that require immediate attention.
Choice E rationale
Birthing parent's report of pain, while important for comfort measures, is subjective and less critical for immediate clinical decision-making compared to the other findings.
Choice F rationale
Fetal heart rate monitoring provides essential information about the baby's well-being during labor. Abnormal heart rate patterns can indicate fetal distress and necessitate prompt intervention.
Correct Answer is B
Explanation
Choice A rationale
Goodell's sign is the softening of the cervix, usually occurring around the fourth to sixth week of pregnancy. It indicates early pregnancy but does not relate to the symptoms described by the client.
Choice B rationale
Lightening refers to the baby settling deeper into the pelvis, which often occurs a few weeks before labor in first-time pregnancies. This shift can make breathing easier and increase pressure on the bladder, causing frequent urination and increased swelling in the lower extremities.
Choice C rationale
Hegar's sign is the softening of the lower uterine segment, typically seen around the sixth to eighth week of pregnancy. It is an early sign of pregnancy and not related to the symptoms experienced by the client near term.
Choice D rationale
Quickening is the term used to describe the first movements of the fetus felt by the mother, usually occurring around 16 to 20 weeks of pregnancy. This does not correlate with the symptoms described by the client who is near term.
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