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
Monitoring vaginal bleeding is the priority nursing action for a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Placenta previa can cause painless, bright red vaginal bleeding during the third trimester. This bleeding can lead to serious complications for both the mother and the fetus, making it crucial to monitor for this symptom.
Choice B rationale
Administering glucocorticoids is not the priority nursing action in this situation. While glucocorticoids can be used to accelerate fetal lung maturity in cases of preterm labor, they are not the primary treatment for placenta previa.
Choice C rationale
Inserting an IV catheter may be necessary for administering medications or fluids, but it is not the priority action. The nurse’s primary concern should be monitoring for signs of bleeding.
Choice D rationale
Applying an external fetal monitor can help assess the well-being of the fetus, but it is not the priority action. The nurse’s main focus should be on monitoring for vaginal bleeding.

A. Flushing and sweating. B. Decreased level of consciousness. C. Urinary output less than 30 mL/hr. D. Respirations fewer than 12/min.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale
Flushing and sweating can be an indication of magnesium sulfate toxicity. Magnesium sulfate is a medication used to prevent seizures in women with severe preeclampsia. However, if the levels of magnesium become too high, it can lead to toxicity15.
Choice B rationale
A decreased level of consciousness can be an indication of magnesium sulfate toxicity. High levels of magnesium can affect the central nervous system, leading to drowsiness, lethargy, and decreased responsiveness15.
Choice C rationale
Urinary output less than 30 mL/hr can be an indication of magnesium sulfate toxicity. Magnesium sulfate can affect kidney function, leading to decreased urine output15.
Choice D rationale
Respirations fewer than 12/min can be an indication of magnesium sulfate toxicity. High levels of magnesium can depress the respiratory system, leading to slow or shallow breathing15.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. What is the priority nursing action?

Correct Answer is A

Explanation

A nurse is administering magnesium sulfate IV to a client with severe preeclampsia for seizure prophylaxis. Which of the following are indications of magnesium sulfate toxicity? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?

A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. What findings should the nurse expect?

A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis?

A nurse is discharging a child who has recovered from an acute crisis episode of sickle cell anemia. What instructions should the nurse include in the teaching?

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. What should the nurse respond?

A nurse is providing care to multiple clients on the postpartum unit. Which of the following clients is at the greatest risk for developing a puerperal infection?

A nurse is caring for an adolescent with spina bifida who is paralyzed from the waist down. Which of the following client statements should alert the nurse to the need for further education?

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?