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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 B

Explanation

The correct answer is choice B.

Choice A rationale:

Focus on the family unit and its members is more characteristic of the “letting-go” phase.

Choice B rationale:

Expressions of excitement are common in the dependent, taking in phase as the mother is focused on her own needs and the experience of childbirth.

Choice C rationale:

Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase.

Choice D rationale:

Lack of appetite is not a typical characteristic of the dependent, taking in phase.

A. Assess the newborn's glucose level. B. Swaddle the infant and place in the bassinet. C. Dry the newborn and place it skin-to-skin on mother. D. Complete a full head-to-toe assessment.

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.

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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

A nurse is caring for a client who experienced a vaginal birth 12 hr ago.The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment.Which of the following findings should the nurse expect during this phase?.

Correct Answer is B

Explanation

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

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia.Which of the following is an expected finding?.

Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and birth.The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?

A nurse is assessing a postpartum woman.Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a fourth-degree laceration.The nurse understands that the laceration extends to which area?.

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

A client presents to the health care clinic for her first prenatal checkup.What nutritional supplement should the nurse discuss with the client to prevent neural tube defects in the developing fetus?

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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?