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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Body weight – Correct; the best indicator of fluid loss in infants is a change in weight because infants have higher water content and small changes can significantly impact hydration status.

B. Blood pressure – Incorrect; infants can maintain blood pressure until dehydration becomes severe.

C. Respiratory rate – Incorrect; respiratory rate may increase with dehydration but is not the most reliable indicator.

D. Skin integrity – Incorrect; poor skin turgor is a sign of dehydration, but weight loss is more objective and accurate.

A. Pressure from the growing uterus displaces the stomach. B. Increased pancreatic activity results in intolerance of fat in the diet. C. Increased progesterone production causes decreased motility of smooth muscle. D. Increased estrogen production causes increased secretion of hydrochloric acid.

Correct Answer is C

Explanation

A. Lightening – Correct; "lightening" occurs when the fetal head descends into the pelvis, reducing pressure on the diaphragm, making it easier to breathe.

B. Decreasing chest diameter – Incorrect; the chest diameter does not decrease; instead, the diaphragm moves upward due to uterine growth.

C. Decreased carbon dioxide production – Incorrect; CO₂ production remains stable during pregnancy.

D. Hyperventilation – Incorrect; while pregnancy increases respiratory effort, the client is experiencing relief, not hyperventilation.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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