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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
Evaluating the firmness of the uterus is the first action the nurse should take when a client’s blood pressure is 60/50 mm Hg after giving birth. A soft or “boggy” uterus can indicate uterine atony, a condition in which the uterus fails to contract after birth. Uterine atony can lead to significant postpartum hemorrhage, which can cause hypotension.
Choice B rationale
Oxygenating by rebreather mask may be necessary if the client shows signs of hypoxia or difficulty breathing, but it is not the first action the nurse should take.
Choice C rationale
Administering oxytocin infusion can stimulate uterine contractions and help control postpartum bleeding. However, the nurse should first assess the firmness of the uterus.
Choice D rationale
Obtaining a type and crossmatch may be necessary if the client needs a blood transfusion, but it is not the first action the nurse should take.

A. Plump face B. Dehydration C. Long nails D. Weak grasp reflex E. Presence of lanugo .

Correct Answer is ["C","D","E"]

Explanation

Choice A rationale
A newborn born at 32 weeks of gestation and weighing 1,100 g is considered preterm and is likely to have a thin, fragile appearance rather than a plump face.
Choice B rationale
Dehydration is not a typical finding in a preterm newborn unless there are underlying health issues or complications.
Choice C rationale
Long nails are a common finding in preterm newborns. This is because nail growth begins in the womb and preterm babies have had less time to wear down their nails through movement.
Choice D rationale
A weak grasp reflex is common in preterm newborns. This is due to their immature nervous system.
Choice E rationale
The presence of lanugo, or fine hair, is common in preterm newborns. Lanugo usually begins to disappear around 32 weeks of gestation, so a baby born at this time may still have a significant amount.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What is the first action the nurse should take?

Correct Answer is A

Explanation

A nurse is assisting with the assessment of a newborn who was born at 32 weeks of gestation. The newborn’s birth weight is 1,100 g. What are the expected findings in this newborn? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is preparing to administer digoxin to a 6-month-old infant. Before administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than what rate? .

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

A nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse anticipate the client will exhibit?

A nurse in a prenatal clinic is providing education to a client who is in the 8th week of gestation. The client states that she does not like milk. What is a good source of calcium that the nurse can recommend to the client?

A nurse in the delivery room is planning to promote maternal-infant bonding for a client who just delivered. What is the priority action by the nurse?

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. How should the nurse classify this neonate based on the weight and gestational age?

A nurse is caring for a laboring patient with an external fetal monitor. The nurse notices late decelerations on the monitor strip. What does the nurse interpret this as indicating?