A nurse is caring for a client in labor. The nurse determines that the client is beginning in the second stage of labor when which of the following assessments is noted?
The contractions are regular
The cervix is fully dilated.
The membranes have ruptured
The provider has ruptured the membranes
The Correct Answer is B
A. The contractions are regular – Incorrect; regular contractions occur throughout labor, not just in the second stage.
B. The cervix is fully dilated. – Correct; the second stage of labor begins when the cervix is completely dilated (10 cm), allowing for pushing and delivery.
C. The membranes have ruptured – Incorrect; rupture of membranes can occur at any stage of labor.
D. The provider has ruptured the membranes – Incorrect; artificial rupture (amniotomy) does not determine the start of the second stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Maturation of germ cells in ovaries – Incorrect; this occurs later in fetal development and after birth.
B. Gender differentiation takes place – Correct; the embryonic stage (weeks 3-8) is when gender differentiation occurs at around week 7-8.
C. Implantation begins – Incorrect; implantation happens in the blastocyst stage (week 1-2), before the embryonic stage.
D. Differentiation begins – Incorrect; cell differentiation starts earlier, in the blastocyst stage, before full embryonic development.
Correct Answer is C
Explanation
A. Polyphagia – Incorrect; this refers to excessive hunger, not the consumption of nonfood items.
B. Polydipsia – Incorrect; this refers to excessive thirst, often linked to conditions like diabetes.
C. Pica – Correct; pica is the craving and consumption of non-nutritive substances (e.g., clay, ice, starch), which can lead to nutritional deficiencies.
D. Polyuria – Incorrect; this refers to excessive urination, not abnormal food cravings.
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