A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Active

Transition

Latent

Descent

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Active is incorrect. The active phase of labor typically begins when the cervix is around 4 to 6 centimeters dilated. Given that the client's cervix is already dilated to 9 cm, she has progressed beyond the active phase.

Choice B Reason:

Transition is correct. The transition phase is the final part of the first stage of labor and occurs when the cervix is dilated from 8 to 10 centimeters. In this phase, contractions are typically strong, occurring every 2 to 3 minutes, and lasting 80 to 90 seconds. The sensation of increasing rectal pressure is common during the transition phase as the baby's head descends further into the birth canal. The advanced cervical dilation to 9 cm also indicates that the client is in the transition phase, preparing for the second stage of labor.

Choice C Reason:

Latent is incorrect. The latent phase is the early part of the first stage of labor, characterized by cervical dilation from 0 to 3 or 4 centimeters. The client's cervix is already dilated to 9 cm, indicating that she has progressed well beyond the latent phase.

Choice D Reason:

Descent is incorrect. The descent phase is generally associated with the second stage of labor, during which the baby moves through the birth canal. The information provided primarily relates to the first stage of labor, specifically the transition phase, as indicated by the cervical dilation of 9 cm.

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Correct Answer is B

Explanation

Choice A Reason:

Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence

Choice B Reason:

Temperature:Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes.The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.

Choice C Reason:

Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.

Choice D Reason:

Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.

A. September 3rd B. September 20th C. August 3rd D. August 20th

Correct Answer is A

Explanation

Nägele's rule is a method used to estimate the expected date of delivery (EDD) for a pregnant woman. To use Nägele's rule, you start with the first day of the last menstrual period (LMP), add one year, subtract three months, and add seven days.

In this case:

LMP: November 27th

Add one year: November 27th of the following year

Subtract three months: August 27th

Add seven days: September 3rd

Therefore, according to Nägele's rule, the expected date of birth is September 3rd

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Naxlex Comprehensive Predictor Exams

A DDA nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Correct Answer is B

Explanation

A nurse is calculating a client's expected date of birth using Nägele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?

Correct Answer is A

Explanation

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