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 ["{"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}"]

Explanation

A. Apply oxygen at 10 L/min via venturi mask:
Anticipated: Applying oxygen is an appropriate action, especially during labor, to ensure adequate oxygenation for both the mother and the fetus.

B. Increase the oxytocin infusion to 13 mu/min:
Anticipated: Adjusting the oxytocin infusion rate may be considered based on the progress of labor and the response to the current infusion rate. This action is anticipated but should be done cautiously and in accordance with established protocols.

C. Initiate a bolus of primary IV fluids:
Anticipated: Initiating a bolus of primary IV fluids is appropriate, especially if there are signs of dehydration or if additional hydration is needed during labor.

D. Perform a sterile vaginal examination (SVE):
Anticipated: Performing a sterile vaginal examination is appropriate to assess cervical dilation, effacement, and station. This information helps in monitoring the progress of labor and making decisions about interventions.

E. Place the client in a side-lying position:
Anticipated: Placing the client in a side-lying position is an appropriate action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.

A. "You will need to drink the glucose solution 2 hours prior to the test." B. "Limit your carbohydrate intake for 3 days prior to the test." C. "A blood glucose of 130 to 140 is considered a positive screening result. D. "You will need to fast for 12 hours prior to the test

Correct Answer is C

Explanation

Choice A Reason:

Drinking the glucose solution 2 hours prior to the test is not standard for a 1-hour GTT. Instead, the glucose solution is usually consumed within a short timeframe, such as 5 minutes, and the blood is drawn 1 hour afterward.

Choice B Reason:

Limiting carbohydrate intake for 3 days prior to the test is not a requirement for a 1-hour GTT. However, it may be advised for a longer fasting period or a different type of glucose tolerance test.

Choice C Reason:

C. “A blood glucose of 130 to 140 is considered a positive screening result.”

In the 1-hour glucose tolerance test during pregnancy, a blood glucose level of135 mg/dL or higheris considered a positive screening result. If this threshold is met, further testing (such as the 3-hour glucose tolerance test) is recommended to confirm or rule out gestational diabetes.

Choice D Reason:

Fasting for 12 hours prior to the test is inappropriate. For a 1-hour GTT, the client is not typically required to fast.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 42 weeks of gestation Exhibits Based on the assessment findings, which of the following actions should the nurse plan to take? (Select All that Apply)

Correct Answer is ["{"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}"]

Explanation

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should Instruct the client to increase her daily intake of which of the following nutrients?

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the Uterus and a long, smooth surface on the client's right side, in which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

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?

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagin

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?