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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should prioritize administering magnesium sulfate and monitoring for signs of magnesium toxicity.
- Administering magnesium sulfate: This is crucial for preventing seizures in patients with preeclampsia, given her symptoms and elevated blood pressure.
- Monitoring for signs of magnesium toxicity: Essential when administering magnesium sulfate, as it can have serious side effects.
Correct Answer is D
Explanation
Choice A rationale
Premature rupture of the membranes refers to the breaking of the amniotic sac before labor starts. It is not a definitive indicator of true labor, as contractions and cervical changes need to accompany it to confirm labor onset.
Choice B rationale
Light irregular pattern of contractions is often associated with false labor or Braxton Hicks contractions. True labor contractions are typically regular, progressively stronger, and closer together.
Choice C rationale
3 station of the presenting part refers to the baby's descent into the pelvis. While it indicates labor progression, it is not the most definitive sign of true labor compared to cervical changes.
Choice D rationale
Progressive cervical dilation is the most reliable indicator of true labor. It signifies that the cervix is opening up in response to regular and effective contractions, indicating the body is preparing for childbirth.
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