Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in:
Select one:

Latent phase of the first stage of labor.

Transition phase of the first stage of labor.

Perineal phase of the second stage of labor.

Active phase of the first stage of labor.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Latent phase of the first stage of labor. This is because this phase is characterized by mild and irregular contractions, slow cervical dilation (up to 4 cm), minimal cervical eﬀacement (up to 40%), and minimal discomfort or pain. The latent phase is also known as the early phase or preparatory phase of labor.

Choice B Reason: Transition phase of the first stage of labor. This is an incorrect answer that describes a diﬀerent phase with diﬀerent characteristics. The transition phase is marked by strong and frequent contractions, rapid cervical dilation (from 8 to 10 cm), complete cervical eﬀacement (100%), and intense discomfort or pain. The transition phase is also known as the terminal phase or acceleration phase of labor.

Choice C Reason: Perineal phase of the second stage of labor. This is an incorrect answer that refers to another stage and phase with diﬀerent features. The second stage of labor begins with complete cervical dilation (10 cm) and ends with delivery of the baby. The perineal phase is the last part of the second stage, where the baby's head crowns and emerges through the vaginal opening.

Choice D Reason: Active phase of the first stage of labor. This is an incorrect answer that indicates another phase with diﬀerent atributes. The active phase is characterized by moderate and regular contractions, progressive cervical dilation (from 4 to 8 cm), increased cervical eﬀacement (from 40% to 80%), and increased discomfort or pain. The active phase is also known as the middle phase or dilatation phase of labor.

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Correct Answer is D

Explanation

Choice A Reason: Possible Meconium Aspiration Syndrome (MAS). This is an unlikely condition for this newborn, as MAS occurs when fetal stool (meconium) enters into the lungs before or during birth, causing airway obstruction, inﬂammation, and infection. MAS usually aﬀects term or post-term infants who experience fetal distress or hypoxia in utero.

Choice B Reason: Possible polycythemia. This is an unrelated condition for this newborn, as polycythemia refers to an abnormally high number of red blood cells in the blood, which can increase blood viscosity and impair circulation.

Polycythemia may occur in infants who have delayed cord clamping, intrauterine growth restriction, maternal diabetes, or high altitude exposure.

Choice C Reason: Possible Transient Tachypnea of the Newborn (TTN). This is a less serious condition than RDS, as TTN is a mild respiratory problem that results from delayed clearance of fetal lung ﬂuid after birth. TTN causes rapid breathing, nasal ﬂaring, grunting, and mild cyanosis. It usually resolves within 24 to 48 hours after birth.

Choice D Reason: Possible Respiratory Distress Syndrome (RDS). This is a serious condition that requires immediate intervention and treatment, as RDS can lead to life-threatening complications such as pulmonary hemorrhage, pneumothorax, or bronchopulmonary dysplasia. RDS causes respiratory distress, nasal ﬂaring, retractions, grunting, and central cyanosis. It usually occurs within minutes to hours after birth.

A. About 1 of every 5 women will experience abuse in her lifetime. B. When women go back to the situation after the abuser has calmed down, things will be beter. C. The victimized woman can easily leave the situation. D. The violence will not stop or decrease if the woman becomes pregnant.

Correct Answer is D

Explanation

Choice A Reason: About 1 of every 5 women will experience abuse in her lifetime is a statistic that shows the prevalence of domestic violence, but it does not address the question of what the nurse should emphasize to the group of women.

Choice B Reason: When women go back to the situation after the abuser has calmed down, things will be beter is a false statement that reﬂects the cycle of abuse, where the abuser may apologize and promise to change after a violent episode, but then repeat the same behavior later. This does not help the women understand their situation or seek help.

Choice C Reason: The victimized woman can easily leave the situation is a false statement that ignores the many barriers and challenges that women face when trying to escape from domestic violence, such as fear, isolation, financial dependence, lack of support, legal issues, and threats from the abuser. This does not empower the women or provide them with realistic options.

Choice D Reason: The violence will not stop or decrease if the woman becomes pregnant is a true statement that highlights the danger of staying in an abusive relationship during pregnancy. Domestic violence can increase the risk of miscarriage, preterm birth, low birth weight, placental abruption, fetal injury, and maternal death. This may motivate the women to seek safety and protection for themselves and their unborn children.

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Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in: Select one:

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Naxlex Comprehensive Predictor Exams

The nurse assesses a newborn at 36 weeks' gestation, and the following behaviors are noted: nasal ﬂaring, labored breathing, and excessive mucus. The nurse is most concerned about: Select one:

Correct Answer is D

Explanation

The nurse at a shelter is counseling a group of women experiencing domestic violence. What is most important for the nurse to emphasize? Select one:

Correct Answer is D

Explanation

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: Select one:

The patient is 34 weeks pregnant and during a regular prenatal visit she asks how to do kick counts. The best response by the nurse would be: Select one:

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? Select one:

If a woman has a pre-existing condition of diabetes, the nurse knows that she would be at risk for what symptom(s) during her pregnancy? Select one:

After the birth of a newborn, the nursing intervention that most eﬀectively promotes parental atachment is: Select one:

When reviewing the causes of late postpartum hemorrhage, which of the following would the nurse identify as the most common cause? Select one:

The nurse administers vitamin K intramuscularly as prophylaxis to the newborn based on which of the following rationales? Select one:

The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygenation needs are not being met? Select one:

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in:
Select one: