In which stage and phase of labor is the client who is at 7 cm of cervical dilation and 100% effacement, with the fetus at 1 station and intact amniotic membranes, and reporting the urge to push?

Second stage, active phase

First stage, active phase

First stage, latent phase

Second stage, latent phase

Answer and Explanation

The Correct Answer is B

A. Second stage, active phase – Incorrect; the second stage begins at 10 cm dilation, not 7 cm.
B. First stage, active phase – Correct; the active phase of the first stage occurs from 6-10 cm dilation and includes increased discomfort and pressure.
C. First stage, latent phase – Incorrect; the latent phase occurs 0-5 cm dilation, before active labor.
D. Second stage, latent phase – Incorrect; the second stage starts at 10 cm when pushing begins.

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Correct Answer is D

Explanation

A. Encourage the client to nurse more frequently so her milk will come in. – Incorrect; milk production typically begins between days 2-5 postpartum, not 14 hours postpartum.

B. Report the client's temperature elevation. – Incorrect; a temperature of 37.7°C (100°F) is within normal postpartum range due to dehydration and hormonal shifts.

C. Increase IV fluids. – Incorrect; IV fluids are not needed unless dehydration is suspected.

D. Ask the client to empty her bladder. – Correct; a fundus deviated to the right suggests a full bladder, which can impede uterine involution and increase postpartum hemorrhage risk.

A. At a non-palpable depth B. At the umbilicus C. 2 cm below the umbilicus D. Just above the symphysis pubis

Correct Answer is B

Explanation

A. At a non-palpable depth – Incorrect; the fundus is still palpable in the immediate postpartum period.
B. At the umbilicus – Correct; at 8 hours postpartum, the fundus is typically at the level of the umbilicus.
C. 2 cm below the umbilicus – Incorrect; the fundus begins to descend around 24 hours postpartum.
D. Just above the symphysis pubis – Incorrect; this occurs around day 10 postpartum.

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In which stage and phase of labor is the client who is at 7 cm of cervical dilation and 100% effacement, with the fetus at 1 station and intact amniotic membranes, and reporting the urge to push?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is 8 hr postpartum. Where should the nurse expect to find the fundus?

Correct Answer is B

Explanation

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