A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is the client experiencing?

First stage, latent phase

Second stage of labor

First stage, active phase

First stage, transition phase

Answer and Explanation

The Correct Answer is A

A. First stage, latent phase: The first stage of labor consists of the latent, active, and transition phases. Latent phase: Cervical dilation 0-3 cm, contractions mild and irregular (every 5-10 minutes, lasting 30-45 seconds). Client in this scenario matches these criteria.

B. Second stage of labor: The second stage of labor begins at full cervical dilation (10 cm) and ends with birth. The client is only 2 cm dilated, so she is still in the first stage.

C. First stage, active phase: The active phase of labor occurs when the cervix is 4-7 cm dilated and contractions are stronger, longer, and more frequent (every 3-5 minutes). The client is only 2 cm dilated, so she is still in the latent phase.

D. First stage, transition phase: The transition phase occurs when the cervix is 8-10 cm dilated, and contractions occur every 2-3 minutes, lasting 60-90 seconds. The client is far from this stage.

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Correct Answer is ["A","B","C"]

Explanation

A. Provide a dark, quiet environment. Clients with severe gestational hypertension are at risk for seizures (eclampsia). A dark, quiet environment helps reduce stimuli that can trigger seizures.

B. Administer magnesium sulfate IV. Magnesium sulfate is the drug of choice to prevent seizures in clients with severe gestational hypertension or preeclampsia.

C. Ensure that calcium gluconate is readily available. Calcium gluconate is the antidote for magnesium sulfate toxicity and should always be available when administering magnesium sulfate.

D. Assess respiratory status every 4 hr. Respiratory status should be assessed more frequently (at least every hour) when administering magnesium sulfate, as respiratory depression is a sign of toxicity.

E. Evaluate neurologic status every 8 hr. Neurologic status should be evaluated at least every 1-2 hours, as changes (e.g., confusion, headaches, hyperreflexia) can indicate worsening preeclampsia or impending seizure activity.

A. Maternal heart rate B. Gestational age C. Uterine contractions D. Presence of accelerations and decelerations

Correct Answer is C

Explanation

A. Maternal heart rate: While the maternal heart rate is important, it is not directly related to interpreting FHR patterns. However, it is necessary to differentiate between the maternal and fetal heart rate on the monitor.

B. Gestational age: While gestational age affects fetal heart rate (younger fetuses tend to have higher baseline rates), it is not a direct component of FHR interpretation.

C. Uterine contractions: Uterine contractions are crucial in FHR interpretation because they influence perfusion to the fetus. Decelerations occurring with contractions may indicate fetal distress (e.g., late decelerations suggest uteroplacental insufficiency).

D. Presence of accelerations and decelerations: Accelerations and decelerations provide key information about fetal well-being. Accelerations indicate fetal well-being, while decelerations may signal hypoxia, cord compression, or uteroplacental insufficiency.

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A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is the client experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

When interpreting fetal heart rate patterns, what other information is considered in addition to baseline and variability?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

What is considered a reactive nonstress test (NST)?

What is a potential challenge for vegetarians on a gestational diabetic diet in pregnancy?

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?