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. Fundus soft, 2 fingerbreadths below the umbilicus – Incorrect; the fundus should be firm, not soft, to prevent postpartum hemorrhage.

B. Fundus firm, 2 fingerbreadths above the umbilicus – Incorrect; a fundus above the umbilicus at 12 hours may indicate bladder distension or uterine atony.

C. Fundus soft, to the right of the umbilicus – Incorrect; a deviated and soft fundus suggests bladder distension, requiring intervention.

D. Fundus firm, at the level of the umbilicus – Correct; at 12 hours postpartum, the fundus should be firm and at the level of the umbilicus, gradually decreasing in height each day.

A. Avoid sitting for long periods of time during the flight to prevent swelling and discomfort. B. Wear compression stockings during the flight to prevent blood clots. C. Avoid using seat belts during the flight to prevent pressure on the abdomen. D. Take frequent walks and do leg exercises during the flight to promote circulation. E. Avoid using electronic devices during the flight to reduce radiation exposure. Take a high dose of vitamin C before the flight to boost the immune system.

Correct Answer is ["A","B","D"]

Explanation

A. Avoid sitting for long periods of time during the flight to prevent swelling and discomfort. – Correct; prolonged sitting can increase the risk of swelling and deep vein thrombosis (DVT).
B. Wear compression stockings during the flight to prevent blood clots. – Correct; compression stockings help improve circulation and reduce the risk of DVT.
C. Avoid using seat belts during the flight to prevent pressure on the abdomen. – Incorrect; seat belts should be worn low, across the hips, for safety.
D. Take frequent walks and do leg exercises during the flight to promote circulation. – Correct; movement reduces the risk of blood clots and swelling.
E. Avoid using electronic devices during the flight to reduce radiation exposure. Take a high dose of vitamin C before the flight to boost the immune system. – Incorrect; radiation exposure from electronic devices is negligible, and there is no evidence that high doses of vitamin C prevent illness during flights.

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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 D

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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