A client arrives in labor and delivery having contractions every 8-10 minutes, lasting 30 seconds, and palpated as hard.Fetal heart rate is 124-138 with good variability.
Maternal vital signs are 98.4°F temp, HR 88, RR 20, BP 112/64. Membranes are intact and vaginal exam reveals: cervix is 80% effaced, 3 cm dilated, head -2 station.
The nurse knows that the patient is in which stage of labor?

First stage of labor, transition phase.

Second stage of labor, active phase.

Second stage of labor, latent phase.

First stage of labor, latent phase.

Answer and Explanation

The Correct Answer is D

Choice A rationale

The first stage of labor, transition phase, is characterized by rapid cervical dilation from 7 cm to 10 cm, intense contractions, and strong desire to push. This client's cervix is only 3 cm dilated, indicating that she is not in the transition phase.

Choice B rationale

The second stage of labor, active phase, is the period from full cervical dilation to the birth of the baby. This stage involves active pushing and the descent of the baby through the birth canal. This client's cervix is not fully dilated, so she cannot be in the second stage.

Choice C rationale

The second stage of labor, latent phase, does not exist. The latent phase is part of the first stage of labor, not the second stage. This choice is incorrect because it misrepresents the stages of labor.

Choice D rationale

The first stage of labor, latent phase, is characterized by regular contractions, cervical effacement, and dilation up to 4 cm. This client's cervix is 80% effaced and 3 cm dilated, indicating that she is in the latent phase of the first stage of labor.

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Correct Answer is A

Explanation

Choice A rationale

Squatting and pelvic lunges are natural positions and exercises that can help with labor progression, but they are not medically recognized methods for inducing labor. These activities may help move the baby into a better position but do not stimulate contractions effectively for labor induction.

Choice B rationale

Amniotomy involves the intentional rupture of the amniotic sac to release amniotic fluid. This procedure can stimulate uterine contractions and is a common method used to induce labor when conditions are appropriate.

Choice C rationale

Oxytocin is a hormone that stimulates uterine contractions. It is commonly administered intravenously to induce or augment labor, making it an effective and widely used method for labor induction.

Choice D rationale

Dinoprostone is a prostaglandin used to ripen the cervix and induce labor. It is applied either as a vaginal insert or gel and helps soften and dilate the cervix, preparing it for labor.

A. Allow the client to ambulate in the hallway to initiate labor. B. Encourage oral fluids and administer an antipyretic medication. C. Administer glucocorticoids intramuscularly. D. Check the client's temperature every 2 hours.

Correct Answer is D

Explanation

Choice A rationale

Allowing the client to ambulate in the hallway to initiate labor is not the first appropriate action because it does not address the immediate need to monitor the client's temperature. Ambulation can be considered after ensuring there are no signs of infection or other complications.

Choice B rationale

Encouraging oral fluids and administering an antipyretic medication is not the initial priority. While hydration is important, the primary focus should be on monitoring for signs of infection, which can be indicated by changes in temperature.

Choice C rationale

Administering glucocorticoids intramuscularly is typically for promoting fetal lung maturity in cases of preterm labor, not for term pregnancies at 38 weeks. It does not address the immediate need to monitor maternal temperature after membrane rupture.

Choice D rationale

Checking the client's temperature every 2 hours is crucial to monitor for signs of infection, such as chorioamnionitis, which can occur after membrane rupture. Early detection of fever can prevent complications for both mother and baby.

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Naxlex Comprehensive Predictor Exams

The nurse knows that which of the following interventions is not useful for induction of labor:

Correct Answer is A

Explanation

A nurse admits a woman who is 38 weeks gestation and has ruptured membranes.The nurse determines that the amniotic fluid is clear and odorless.Besides notifying the provider, which of the following is the appropriate first nursing action?

Correct Answer is D

Explanation

A newborn who weighs 4300 grams is receiving ampicillin 2mg/kg IV once per day. The vial reads 20mg/mL. How much will the nurse draw up in the syringe for one dose? (Enter your answer in numbers only. No units.)

A nurse is caring for a client who is gravida 3, para 2, and is in active labor.The fetal head is at 5+ station after a vaginal examination.Which of the following actions should the nurse take?

A nurse is caring for a client who is in active labor and notes persistent late decelerations on the fetal monitor.Which of the following are the priority nursing actions? (Select all that apply.)

A primigravida dilated to 5 cm will receive an epidural for pain.Which of the following interventions will help prevent hypotension in the patient?

Using Leopold's Maneuvers, the fetus is found to be with its occiput facing toward the left maternal spine.The mother is complaining of increased back labor pain.The nurse knows that the fetus is in which position?

A nurse is caring for a client who is in the first stage of labor.The nurse observes the umbilical cord protruding from the vagina.Which of the following actions should the nurse NOT perform?