The nurse is digitally removing a fecal impaction for a client. Which vital sign change is expected during this procedure?

• A. Blood pressure increases
• B. Respiratory rate decreases
• C. Pulse rate decreases from 78 to 52 beats/min
• D. Temperature decreases

Answer: (C)

Stimulation of the rectal mucosa during disimpaction can trigger a vasovagal response that slows the heart rate. This vagal reflex often leads to bradycardia and may be accompanied by a drop in blood pressure. A pulse rate dropping from 78 to 52 beats per minute is the classic sign of this reflex, so a decrease in pulse is the expected vital sign change during the procedure.

The other options don’t fit this reflex pattern—a rise in blood pressure isn’t typical, respiratory rate isn’t predictably decreased, and temperature changes aren’t expected with this procedure. Be prepared to monitor closely and stop stimulation if bradycardia or hypotension becomes significant.