The labor and delivery nurse tells her client she has completed stage 1 of labor.

Which of the following statements by the student nurse indicates confusion about the stages of labor?

Stage 2 starts with the delivery of the placenta and ends with the delivery of the fetus.

Stage 2 starts with complete effacement and dilation.

Stage 2 starts when the patient’s cervix is dilated enough to start pushing.

Stage 2 starts with the delivery of the fetus and ends with the delivery of the placenta.

Answer and Explanation

The Correct Answer is A

Choice A rationale
This statement is incorrect because Stage 2 of labor does not involve the delivery of the placenta. Stage 2 starts with the complete dilation and effacement of the cervix and ends with the delivery of the fetus. The delivery of the placenta occurs in Stage 3 of labor.
Choice B rationale
This statement is correct. Stage 2 of labor begins with complete effacement and dilation of the cervix. This stage is characterized by the mother pushing and the eventual delivery of the baby.
Choice C rationale
This statement is also correct. Stage 2 starts when the cervix is fully dilated, allowing the mother to start pushing. This stage continues until the baby is born.
Choice D rationale
This statement is incorrect. Stage 2 ends with the delivery of the fetus, not the placenta. The delivery of the placenta is part of Stage 3 of labor.

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Correct Answer is B

Explanation

Choice A rationale
Early decelerations are characterized by a gradual decrease and return to baseline of the fetal heart rate that coincides with the peak of a contraction. They are typically benign and related to fetal head compression.
Choice B rationale
Late decelerations are characterized by a gradual decrease and return to baseline of the fetal heart rate that occurs after the peak of a contraction. They are associated with uteroplacental insufficiency and require prompt intervention to improve fetal oxygenation.
Choice C rationale
Variable decelerations are characterized by an abrupt decrease in fetal heart rate that varies in duration, intensity, and timing relative to contractions. They are often caused by umbilical cord compression and may require interventions to relieve the compression.
Choice D rationale
Prolonged decelerations are characterized by a decrease in fetal heart rate that lasts longer than 2 minutes but less than 10 minutes. They indicate a more severe and sustained disruption in fetal oxygenation and require immediate intervention.

A. Keep four side rails up. B. Insert an indwelling urinary catheter. C. Check the cervix prior to administering medication. D. Monitor the fetal heart rate (FHR) every hour.

Correct Answer is C

Explanation

Choice A rationale
Keeping four side rails up is a safety measure to prevent falls, but it is not specific to the care of a client in active labor. It is a general safety precaution used for clients who are at risk of falling or have impaired mobility.
Choice B rationale
Inserting an indwelling urinary catheter is not a routine action for a client in active labor. Catheterization is typically reserved for specific medical indications, such as urinary retention or the need for accurate urine output measurement in certain high-risk situations.
Choice C rationale
Checking the cervix prior to administering medication is crucial in active labor. This ensures that the medication is appropriate for the stage of labor and helps avoid complications such as administering pain relief too early or too late, which could affect labor progression and fetal well-being.
Choice D rationale
Monitoring the fetal heart rate (FHR) every hour is important, but it may not be frequent enough in active labor. Continuous or more frequent monitoring is often required to promptly detect any signs of fetal distress and take appropriate actions.

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The labor and delivery nurse tells her client she has completed stage 1 of labor. Which of the following statements by the student nurse indicates confusion about the stages of labor?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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The labor and delivery nurse tells her client she has completed stage 1 of labor.

Which of the following statements by the student nurse indicates confusion about the stages of labor?