The nurse assesses a patient during digital removal of a fecal impaction.Which patient assessment finding does the nurse determine to be unexpected?

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Sinus bradycardia is a heart rate less than 60 beats/min and is consistent with clinical indicators for vasovagal stimulation from digital removal of fecal impaction.This heart rate is usually too slow to maintain an adequate cardiac output; thus the patient becomes hypotensive and lightheaded and may lose consciousness.The nurse stops the procedure,assesses patient vital signs and neurological status,and calls for help in anticipation of the need for emergency interventions.Usually bradycardia from vasovagal stimulation resolves spontaneously; however,the nurse also notifies the provider to deliver safe and effective nursing care.The nurse expects abdominal cramping; he or she instructs the patient to focus on slow,even breathing and proceeds with removal slowly and gently to minimize cramping.The patient can pass a large amount of stool after some or the entire impacted stool is removed because fecal matter frequently accumulates behind the impaction in the colon.Stable blood pressure is a highly desirable finding.

The Nurse Assesses a Patient During Digital Removal of a Fecal