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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward. This is an appropriate action for the nurse to perform during the third stage of labor, as it helps complete the process of labor and prevent complications.
Choice B Reason: Palpating the woman's fundus for position and firmness. This is an action that is done after the delivery of the placenta, not during. It is important to monitor the fundal height, location, and consistency to assess uterine involution and bleeding.
Choice C Reason: Encouraging the woman to push with her contractions. This is an action that is done during the second stage of labor, not the third. The second stage of labor is the period from full cervical dilation to the birth of the baby. The nurse's role is to support and coach the woman to push effectively with her contractions.
Choice D Reason: Alleviating perineal discomfort with the application of ice packs. This is an action that is done after the delivery of the placenta, not during. It is a comfort measure that can reduce swelling, pain, and inflammation in the perineal area.
Correct Answer is B
Explanation
Choice A Reason: Pulmonary edema is a condition where fluid accumulates in the lungs, causing shortness of breath and difficulty breathing. It can occur in preeclampsia due to increased blood pressure and fluid retention, but it is not a definitive sign of eclampsia.
Choice B Reason: Convulsion (seizure) is a sudden, involuntary contraction of muscles that can cause loss of consciousness, shaking, and twitching. It is the main symptom of eclampsia and distinguishes it from preeclampsia.
Choice C Reason: Renal failure is a condition where the kidneys fail to filter waste products from the blood, resulting in high levels of creatinine and urea. It can occur in preeclampsia due to reduced blood flow to the kidneys, but it is not a specific indicator of eclampsia.
Choice D Reason: Retinal edema is a condition where fluid leaks into the retina, causing blurred vision and flashes of light. It can occur in preeclampsia due to increased blood pressure and damage to the blood vessels in the eye, but it is not a characteristic feature of eclampsia.
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