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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:

Stimulating the infant to cry is important, but it is not the first action to be taken.

Choice B rationale:

Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly.

Choice C rationale:

Drying the infant off and covering the head is done after the respiratory tract is cleared.

Choice D rationale:

Cutting the umbilical cord is done after the infant is stabilized.

A. She did her perineal care independently. B. She is eager to talk about her birth experience. C. She has not asked for anything for pain all day. D. She sits and rocks her infant for long intervals.

Correct Answer is A

Explanation

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

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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 just delivered a newborn.Following the delivery, which nursing action should be done first to care for the newborn?

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad.The fundus is midline and firm at the umbilicus.Which of the following actions should the nurse take?.

A client in the third stage of labor has experienced placental separation and expulsion.Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm?.

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions?.

The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider.Which signs and symptoms would the nurse include? Select all that apply.

Which documentation in the health record is most correct for the third stage of labor?

A nurse is completing discharge instructions for a new mother and her 2-day-old newborn.The mother asks, "How will I know if my baby gets enough breast milk?" which of the following responses should the nurse make?.

A nurse is teaching a newborn's parent to care for the umbilical cord stump.Which of the following instructions should the nurse include?.

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?