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 ["A","B"]
Explanation
A. Methicillin-resistant Staphylococcus aureus (MRSA) – Correct; requires contact precautions due to the risk of direct and indirect transmission.
B. Vancomycin-resistant Enterococcus (VRE) – Correct; requires contact precautions as it spreads through contaminated surfaces and hands.
C. Pertussis – Incorrect; pertussis is transmitted via droplets, so droplet precautions are needed.
D. Influenza – Incorrect; influenza spreads via droplets, requiring droplet precautions.
E. Group A Streptococcus B-hemolytic – Incorrect; requires droplet precautions, unless skin infections are present, which would then require contact precautions.
Correct Answer is A
Explanation
A. Quickening – Correct; the first sensation of fetal movement, typically felt between 16-20 weeks of gestation.
B. Ballottement – Incorrect; this refers to a physical examination finding where the fetus rebounds when the cervix is tapped.
C. Lightening – Incorrect; this occurs later in pregnancy when the fetus drops into the pelvis before labor.
D. Nesting – Incorrect; this describes a surge of energy before labor, not fetal movement.
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