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A nurse is caring for a pregnant client in labor in a health care facility.
The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?

Cervix dilation of 5 cm with 50% effacement.

Rupturing of fetal membranes.

Start of regular contractions.

Cervix dilation of 10 cm with 100% effacement.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D.

Choice A rationale:

Cervix dilation of 5 cm with 50% effacement is a sign of active phase of the first stage of labor, not the end of it.

Choice B rationale:

Rupturing of fetal membranes can occur at any time during labor, not specifically at the end of the first stage.

Choice C rationale:

Start of regular contractions is a sign of the onset of labor, not the end of the first stage.

Choice D rationale:

Cervix dilation of 10 cm with 100% effacement indicates the end of the first stage of labor and the beginning of the second stage.

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Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

While it’s important to monitor a newborn’s glucose level, it’s not the immediate priority following birth.

Choice B rationale:

Placing the infant in the bassinet is not the immediate priority. The newborn needs to be dried and warmed first to prevent hypothermia.

Choice C rationale:

Drying the newborn and placing it skin-to-skin on the mother helps prevent hypothermia and promotes bonding. This is the immediate priority.

Choice D rationale:

A full head-to-toe assessment is important, but it’s not the immediate priority following birth.

A. Constipation. B. Weight gain. C. Bloody show. D. Lightening. E. Backache.

Correct Answer is ["C"]

Explanation

The correct answers are choices C, D, and E.

Choice A rationale:

Constipation is not a sign of labor. It is more commonly associated with pregnancy rather than the onset of labor.

Choice B rationale:

Weight gain is not a sign of labor. In fact, weight gain often stops as labor approaches.

Choice C rationale:

Bloody show is a sign of labor. It is the discharge of the mucus plug that seals the cervix during pregnancy.

Choice D rationale:

Lightening, or the baby dropping into the pelvis, is a sign of labor.

Choice E rationale:

Backache can be a sign of labor, as the muscles and joints stretch and shift in preparation for childbirth.

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A nurse is caring for a pregnant client in labor in a health care facility.The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action would be a priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?.

Correct Answer is C

Explanation

Correct Answer is ["C"]

Explanation

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A nurse is caring for a pregnant client in labor in a health care facility.
The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?