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?

Choice A rationale
Supporting the casted arm with a firm grasp is important to prevent unnecessary movement and potential discomfort or injury to the child. It also helps in ensuring the correct positioning of the cast.
Choice B rationale
Placing a heated fan at the bedside to facilitate drying is not recommended. Excessive heat can cause discomfort and potential burns to the child. The cast should be allowed to dry naturally.
Choice C rationale
Telling the child that the cast will make their arm feel better can be misleading. While the cast is necessary for healing, it may cause discomfort and itching. It’s important to explain to the child what the cast is for and what to expect.
Choice D rationale
Wrapping the arm of the child’s doll or toy prior to the procedure can help the child understand what is happening and make them feel more comfortable. However, this action alone is not sufficient in preparing to apply a cast to a preschooler’s arm.

Choice A rationale
While an area of warmth can be a symptom of deep vein thrombosis (DVT), it is not the most specific or indicative symptom. DVT is a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs. The most common symptoms include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
However, these symptoms can also be associated with other conditions, making them less specific for DVT.
Choice B rationale
Nausea is not typically a symptom of deep vein thrombosis (DVT). The most common symptoms of DVT include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
Choice C rationale
A cool-to-touch extremity is not typically a symptom of deep vein thrombosis (DVT). In fact, the skin over the affected area is often warmer than the skin on surrounding areas. Therefore, a cool-to-touch extremity would not typically be expected in a client with suspected DVT.
Choice D rationale
Calf tenderness when massaged is a common clinical finding in clients with deep vein thrombosis (DVT)2. DVT often causes pain and swelling in the affected leg, and this pain can be particularly noticeable or worsen when the calf is massaged or the client is standing or walking. Therefore, calf tenderness when massaged would be a clinical finding that a nurse should anticipate in a client being admitted with a suspected DVT.