The nurse is admitting a pregnant client into the labor and delivery unit. Which findings indicate the client is in the latent phase of the first stage of labor? Select all that apply.

Cervical dilation of 5 cm

Cervical effacement of 50%

Contractions lasting about 30 to 45 seconds

Moderate contraction intensity

Contractions occurring every 5 to 10 minutes

Answer and Explanation

Correct Answer : B,C,E

A.   Cervical dilation of 5 cm typically indicates the active phase rather than the latent phase of the first stage of labor.

B.   Cervical effacement of 50% is consistent with the latent phase, where cervical effacement is a prominent feature.
C.   Contractions lasting about 30 to 45 seconds are characteristic of the latent phase.

D. Moderate contraction intensity is more typical of the active phase of the first stage of labor.

E. Contractions occurring every 5 to 10 minutes are consistent with the latent phase, where contractions are typically less frequent than in the active phase.

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Correct Answer is D

Explanation

A. Oxytocin is administered to enhance contractions, not to slow them down.

B. While increased blood flow through the placenta is important for fetal well-being, oxytocin is primarily used to stimulate uterine contractions.
C. Increased urinary output is not the primary effect of oxytocin; its main action is to stimulate uterine contractions.

D. Oxytocin is commonly used to induce or augment labor by stimulating contractions of the uterus.

A. Industry vs. inferiority B. Initiative vs. guilt C. Identity vs. role confusion D. Autonomy vs. shame and doubt

Correct Answer is A

Explanation

A. A 9-year-old is in the school-age period, which corresponds to Erikson’s stage of industry vs. inferiority. During this stage, children focus on developing skills, gaining competence, and seeking approval for accomplishments. Supporting independence in asthma care (such as learning to use an inhaler) fosters a sense of industry.
B. Initiative vs. guilt is the stage for preschool-aged children (3–6 years), where the focus is on asserting power and control through play and social interactions.

C. Identity vs. role confusion is more applicable to adolescence and focuses on the formation of a stable self-identity.

D. Autonomy vs. shame and doubt is relevant to the toddler age range, emphasizing the development of independence. While independence is important, the immediate concern in the given scenario aligns more with the initiative and responsibility associated with the school-age child.

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The nurse is admitting a pregnant client into the labor and delivery unit. Which findings indicate the client is in the latent phase of the first stage of labor? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in labor receiving oxytocin. The client asks the nurse, "What is this medication for?" What is the best response by the nurse?

Correct Answer is D

Explanation

A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson’s developmental stages should the nurse consider in the planning?

Correct Answer is A

Explanation

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