Level: Clinical
Difficulty: Medium
Subtopic: Pain management in labor
NCLEX: A 29-year-old client in labor and delivery is being evaluated for labor with epidural analgesia. Assessment data…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 29-year-old client in labor and delivery is being evaluated for labor with epidural analgesia. Assessment data include the client reports rectal pressure and an urge to push during active labor. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that reports rectal pressure and an urge to push during active labor.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that reports rectal pressure and an urge to push during active labor.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that reports rectal pressure and an urge to push during active labor.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.