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 A
Explanation
Choice A rationale
A newborn’s heart rate normally varies between 120 and 160 beats per minute, but it can rise to 180 beats per minute when the infant is crying or drop as low as 80 to 90 beats per minute when in deep sleep. Therefore, an apical heart rate of 130/min is within the normal range for a newborn.
Choice B rationale
There is no need to call the provider for further assessment if the newborn’s heart rate is within the normal range.
Choice C rationale
Preparing the newborn for transport to the NICU is not necessary if the heart rate is within the normal range.
Choice D rationale
Asking another nurse to verify the heart rate is not necessary if the heart rate is within the normal range.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
A newborn born at 32 weeks of gestation and weighing 1,100 g is considered preterm and is likely to have a thin, fragile appearance rather than a plump face.
Choice B rationale
Dehydration is not a typical finding in a preterm newborn unless there are underlying health issues or complications.
Choice C rationale
Long nails are a common finding in preterm newborns. This is because nail growth begins in the womb and preterm babies have had less time to wear down their nails through movement.
Choice D rationale
A weak grasp reflex is common in preterm newborns. This is due to their immature nervous system.
Choice E rationale
The presence of lanugo, or fine hair, is common in preterm newborns. Lanugo usually begins to disappear around 32 weeks of gestation, so a baby born at this time may still have a significant amount.
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