A nurse is caring for a client in labor. The nurse determines that the client is beginning in the second stage of labor when which of the following assessments is noted?

The contractions are regular

The cervix is fully dilated.

The membranes have ruptured

The provider has ruptured the membranes

Answer and Explanation

The Correct Answer is B

A. The contractions are regular – Incorrect; regular contractions occur throughout labor, not just in the second stage.

B. The cervix is fully dilated. – Correct; the second stage of labor begins when the cervix is completely dilated (10 cm), allowing for pushing and delivery.

C. The membranes have ruptured – Incorrect; rupture of membranes can occur at any stage of labor.

D. The provider has ruptured the membranes – Incorrect; artificial rupture (amniotomy) does not determine the start of the second stage.

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Correct Answer is B

Explanation

A. Dilation – Incorrect; dilation refers to the opening of the cervix, not its thinning.

B. Effacement – Correct; effacement refers to the thinning and shortening of the cervix as labor progresses.

C. Ballottement – Incorrect; ballottement is the rebound of the fetus when tapped during a vaginal exam.

D. Multiparous – Incorrect; multiparous refers to a woman who has given birth multiple times.

A. "There is no way to predict how long it will last for each individual client, so you'll just have to wait and see." B. "No, it should only last until about your 12th week, but it will return near the end of the pregnancy." C. "Yes, it will, but if you decrease your fluid intake, especially at bedtime, it won't be so bothersome." D. "No, in most cases it only lasts until about the 12th week, but it will continue if you have poor bladder tone."

Correct Answer is B

Explanation

A. "There is no way to predict how long it will last for each individual client, so you'll just have to wait and see." – Incorrect; this does not provide helpful education.
B. "No, it should only last until about your 12th week, but it will return near the end of the pregnancy." – Correct; urinary frequency occurs in the first trimester due to hormonal changes and again in the third trimester due to fetal pressure on the bladder.
C. "Yes, it will, but if you decrease your fluid intake, especially at bedtime, it won't be so bothersome." – Incorrect; reducing fluid intake may cause dehydration.
D. "No, in most cases it only lasts until about the 12th week, but it will continue if you have poor bladder tone." – Incorrect; bladder tone does not significantly affect this symptom.

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A nurse is caring for a client in labor. The nurse determines that the client is beginning in the second stage of labor when which of the following assessments is noted?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following terms is used to describe the thinning and shortening of the cervix that occurs just before and during labor?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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