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 D

Explanation

A. "This monitor gives me information related to fetal heart rate fluctuations during your labor." – Incorrect; the TOCO does not monitor fetal heart rate; the fetal heart rate is detected using a Doppler or fetal scalp electrode.

B. "This monitor measures the intensity and frequency of your contractions so I can observe labor progress." – Incorrect; the TOCO can measure frequency and duration, but not intensity (which requires an intrauterine pressure catheter).

C. "This monitor allows me to observe your labor progress. By observing the pattern, I can tell how strong your contractions are." – Incorrect; TOCO does not measure contraction strength, only duration and frequency.

D. "This monitor provides me with information related to the duration and frequency of your contractions." – Correct; a TOCO detects and records contraction frequency and duration, but not intensity.

A. Lightening B. Decreasing chest diameter C. Decreased carbon dioxide production D. Hyperventilation

Correct Answer is A

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

A nurse assisting in the care of a client, places the tocodynamometer (TOCO) transducer on a client's fundus and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A client who is at 39 weeks of gestation tells the nurse, "It has been hard to take a deep breath throughout the pregnancy, but in the past week, I feel like I can breathe again." The nurse should recognize that the client is experiencing the effects of which of the following?

Correct Answer is A

Explanation

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