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
While fat-soluble vitamins are essential for overall health, they do not specifically prevent iron deficiency anemia. Iron deficiency anemia occurs when the body doesn’t have enough iron to produce hemoglobin, the part of red blood cells that gives them their red color and enables them to carry oxygen in the blood.
Choice B rationale
Limiting intake of high-protein foods is not a recommended method for preventing iron deficiency anemia. In fact, many high-protein foods, such as meat and eggs, are good sources of iron.
Choice C rationale
While fluoridated water can help prevent tooth decay, it does not prevent iron deficiency anemia. Iron deficiency anemia is prevented by consuming adequate amounts of iron, either from food sources or from supplements.
Choice D rationale
A diet that consists primarily of milk, particularly cow’s milk, can contribute to iron deficiency anemia. Cow’s milk is low in iron and can also decrease absorption of iron and irritate the lining of the intestine, causing small amounts of bleeding and the gradual loss of iron in the stool (poop)4.
Correct Answer is A
Explanation
Choice A rationale
Cervical dilation is a key sign that labor has begun. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a physical change that can be measured during a pelvic exam.
Choice B rationale
Pain above the umbilicus is not typically a sign of labor. During labor, contractions are usually felt as a tightening or cramping in the lower abdomen or back.
Choice C rationale
Brownish vaginal discharge can occur during pregnancy and is not necessarily a sign of labor. If the discharge is heavy, or accompanied by other symptoms such as pain or cramping, it should be evaluated by a healthcare provider.
Choice D rationale
The presence of amniotic fluid in the vaginal vault, also known as “water breaking,” can be a sign that labor is imminent. However, it does not confirm that labor has begun, as it can occur before the onset of contractions and cervical dilation.
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