A nurse in the labor and delivery unit is attending to a client in labor. The nurse applies an external fetal monitor and toco transducer.
The FHR is around 140/min.
Contractions are every 8 min and 30 to 40 seconds in duration.
The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station.
Which stage and phase of labor is this client experiencing?
The first stage, active phase.
The first stage, transition phase.
The second stage of labor.
The first stage, latent phase.
The Correct Answer is D
Choice D rationale
The client is experiencing the first stage, latent phase of labor. This phase is characterized by contractions that are typically mild and irregular, occurring every 5-30 minutes and lasting about 30-45 seconds. The cervix dilates from 0 to 3 cm and effaces from 0% to 40%. The fetus descends into the pelvis, but is not yet engaged. The client may feel excited and anxious as labor begins.
Choice A rationale
The first stage, active phase of labor is characterized by regular, strong contractions occurring every 3-5 minutes and lasting about 40-70 seconds. The cervix dilates from 4 to 7 cm and effaces from 40% to 100%. The fetus descends and engages in the pelvis. The client may feel increased discomfort and a strong urge to bear down.
Choice B rationale
The first stage, transition phase of labor is characterized by intense contractions occurring every 2-3 minutes and lasting about 45-90 seconds. The cervix dilates from 8 to 10 cm and effaces from 100%. The fetus descends and engages in the pelvis. The client may feel overwhelmed, restless, and irritable.
Choice C rationale
The second stage of labor begins when the cervix is fully dilated and ends with the delivery of the baby. The contractions are strong, occurring every 2-3 minutes and lasting about 45-90 seconds. The client feels a strong urge to push during contractions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug (NSAID) that reduces fever, pain and inflammation. It is used to treat moderate to severe osteoarthritis, rheumatoid arthritis, gouty arthritis, or ankylosing spondylitis. It is not used to accelerate fetal lung maturity.
Choice B rationale
Nifedipine (Procardia) is a calcium channel blocker used to treat high blood pressure (hypertension) or chest pain (angina). It is not used to accelerate fetal lung maturity.
Choice C rationale
Calcium gluconate is used to prevent or to treat calcium deficiencies. It is not used to accelerate fetal lung maturity.
Choice D rationale
Betamethasone (Celestone) is a corticosteroid that is used to mature the lungs in fetuses at risk for preterm birth.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
The G in GTPAL stands for gravida, which is the number of times an individual has conceived, including any current pregnancy. In this case, G3 means the client has had three pregnancies, which includes two prior pregnancies and the current one.
Choice B rationale
The client’s record does not indicate that she is currently pregnant with twins, making this choice incorrect.
Choice C rationale
The A in GTPAL stands for the number of abortions, which refers to all times the individual has lost a pregnancy before 20 weeks. In this case, A1 means the client has had one abortion, indicating a risk for miscarriage.
Choice D rationale
The T in GTPAL stands for term births, which refers to the number of times an individual has carried a pregnancy to at least 37 weeks of gestation and delivered. In this case, T1 means the client has had one full-term birth.
Choice E rationale
The L in GTPAL stands for living children. In this case, L1 means the client has one living child.
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