A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is the client experiencing?

First stage, latent phase

Second stage of labor

First stage, active phase

First stage, transition phase

Answer and Explanation

The Correct Answer is A

A. First stage, latent phase: The first stage of labor consists of the latent, active, and transition phases. Latent phase: Cervical dilation 0-3 cm, contractions mild and irregular (every 5-10 minutes, lasting 30-45 seconds). Client in this scenario matches these criteria.

B. Second stage of labor: The second stage of labor begins at full cervical dilation (10 cm) and ends with birth. The client is only 2 cm dilated, so she is still in the first stage.

C. First stage, active phase: The active phase of labor occurs when the cervix is 4-7 cm dilated and contractions are stronger, longer, and more frequent (every 3-5 minutes). The client is only 2 cm dilated, so she is still in the latent phase.

D. First stage, transition phase: The transition phase occurs when the cervix is 8-10 cm dilated, and contractions occur every 2-3 minutes, lasting 60-90 seconds. The client is far from this stage.

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Correct Answer is B

Explanation

A. "I should schedule the test when the baby is usually active." The test relies on fetal movements to assess heart rate responses, so scheduling it when the baby is active improves accuracy.

B. "I will have to lie on my back during the test." Lying on the back (supine) can cause supine hypotensive syndrome by compressing the inferior vena cava. The client should lie in a semi-Fowler’s or left lateral position.

C. "My baby's heart rate will be monitored during the test." The NST assesses fetal heart rate patterns in response to movement, so monitoring the fetal heart rate is essential.

D. "It will take 20 to 30 minutes to complete the test." An NST typically lasts 20-30 minutes unless additional monitoring is needed due to a nonreactive result.

A. Heart rate of 56/min B. Urine output of 50 mL in 4hr C. Diminished deep-tendon reflexes D. Respiratory rate of 16/min

Correct Answer is D

Explanation

A. Heart rate of 56/min. Bradycardia (HR <60/min) can indicate magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to cardiac complications.

B. Urine output of 50 mL in 4 hr. Urine output should be at least 30 mL/hr (120 mL in 4 hours). Oliguria (low urine output) may indicate magnesium toxicity due to impaired renal excretion.

C. Diminished deep-tendon reflexes. Mildly decreased reflexes may be expected with magnesium therapy, but absent or significantly diminished deep tendon reflexes (DTRs) are an early sign of magnesium toxicity.

D. Respiratory rate of 16/min. A respiratory rate of ≥12 breaths/min indicates that the client is not experiencing respiratory depression, a major concern with magnesium sulfate toxicity. Magnesium should be discontinued if respiratory rate drops below 12/min.

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A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is the client experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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