A nurse in the labor and delivery unit is attending to a client in labor. The nurse applies an external fetal monitor and toco transducer.
The FHR is around 140/min.
Contractions are every 8 min and 30 to 40 seconds in duration.
The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station.
Which stage and phase of labor is this client experiencing?
The first stage, active phase.
The first stage, transition phase.
The second stage of labor.
The first stage, latent phase.
The Correct Answer is D
Choice D rationale
The client is experiencing the first stage, latent phase of labor. This phase is characterized by contractions that are typically mild and irregular, occurring every 5-30 minutes and lasting about 30-45 seconds. The cervix dilates from 0 to 3 cm and effaces from 0% to 40%. The fetus descends into the pelvis, but is not yet engaged. The client may feel excited and anxious as labor begins.
Choice A rationale
The first stage, active phase of labor is characterized by regular, strong contractions occurring every 3-5 minutes and lasting about 40-70 seconds. The cervix dilates from 4 to 7 cm and effaces from 40% to 100%. The fetus descends and engages in the pelvis. The client may feel increased discomfort and a strong urge to bear down.
Choice B rationale
The first stage, transition phase of labor is characterized by intense contractions occurring every 2-3 minutes and lasting about 45-90 seconds. The cervix dilates from 8 to 10 cm and effaces from 100%. The fetus descends and engages in the pelvis. The client may feel overwhelmed, restless, and irritable.
Choice C rationale
The second stage of labor begins when the cervix is fully dilated and ends with the delivery of the baby. The contractions are strong, occurring every 2-3 minutes and lasting about 45-90 seconds. The client feels a strong urge to push during contractions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Terbutaline does not typically cause a decrease in maternal blood glucose levels. It is a medication used to relax the muscles in the uterus to prevent premature labor.
Choice B rationale
Terbutaline does not enhance the production of fetal lung surfactant. It is used to relax the muscles in the uterus to prevent premature labor.
Choice C rationale
Weakened uterine contractions are an expected finding in a client who has received terbutaline. Terbutaline is a tocolytic medication, which means it works to inhibit uterine contractions in order to prevent or halt preterm labor.
Choice D rationale
Terbutaline does not typically cause a decrease in fetal heart rate. It is used to relax the muscles in the uterus to prevent premature labor.
Correct Answer is B
Explanation
Choice A rationale
Performing nasopharyngeal suctioning for a maximum of 5 seconds is not a recommended action for an infant diagnosed with Tetralogy of Fallot. This procedure is typically used to clear the airway in infants with respiratory distress, not heart conditions.
Choice B rationale
Positioning the infant in a knee-chest position can help increase blood flow to the lungs, which is beneficial for an infant with Tetralogy of Fallot. This condition involves a combination of heart defects that affect the normal flow of blood through the heart.
Choice C rationale
Administering morphine via IV bolus is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While morphine is a powerful pain reliever, it is not typically used in the management of this condition.
Choice D rationale
Providing 100% oxygen by face mask is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While supplemental oxygen can help increase the amount of oxygen in the blood, it does not address the underlying heart defects associated with this condition.
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