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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

Taking pressure off of the presenting part of the fetal head can help improve blood flow and oxygen supply to the fetus, potentially preventing hypoxia.

Choice B rationale

Preparing the client for an immediate cesarean birth is a necessary step in cases of umbilical cord prolapse to quickly deliver the baby and reduce the risk of fetal distress.

Choice C rationale

Placing the client in a knee-chest position helps to alleviate pressure on the umbilical cord, increasing blood flow and oxygen supply to the fetus.

Choice D rationale

Attempting to gently put the cord back inside is not recommended as it can cause more harm and increase the risk of cord compression and infection.

A. Goodell's sign. B. Lightening. C. Hegar's sign. D. Quickening.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

A 3800 gram newborn was admitted to the neonatal intensive care unit at 39 weeks with meconium aspiration. Metoclopramide 0.1 mg/kg every 12 hours was started. On hand is Metoclopramide 0.5 mg/ml. What is the appropriate dose the RN will administer in ml in 12 hours?

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 nurse reviews assessment findings. For each assessment finding, specify if the finding is consistent with a urinary tract infection or preterm labor. Each finding may support more than one disease process.

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?

A neonatologist prescribes gentamicin for a 2-day-old, septic preterm infant who weighs 2800 grams. The dosage of gentamicin for babies under 1 week of age is 2.5 mg/kg every 24 hours. The nurse calculates the safe daily dosage of this medication as?

A nurse is caring for a 34-year-old female client who is at 34 weeks of gestation in the labor and delivery unit. Below are the exhibits and the questions based on the client's condition. Exhibits What are the priority nursing interventions for this client? Select all that apply.

A nurse is caring for several clients.The nurse should recognize that it is appropriate to administer tocolytic therapy to which of the following clients?