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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. "There are so many variables that you'll have to ask your obstetrician."
A. "It's too soon for you to be worrying about this now" dismisses the client's concerns and does not provide useful information. It's important to address the client's question and offer guidance.
B. "A repeat cesarean birth is safer for both you and your baby" may not be accurate for all situations. The decision on the mode of delivery (vaginal birth after cesarean - VBAC or repeat cesarean) depends on various factors, and a blanket statement may not apply.
C. "The primary consideration is what type of incision was performed this time" is partially correct.
The type of uterine incision in the current cesarean birth is one factor to consider, but it is not the only consideration. Other factors, such as the reason for the previous cesarean, maternal health, and the obstetrician's assessment, also play a role.
D. "There are so many variables that you'll have to ask your obstetrician" is the most appropriate response.
The decision regarding the mode of delivery in subsequent pregnancies after a cesarean is individualized and depends on various factors. The obstetrician will consider the woman's health, the reason for the previous cesarean, the type of uterine incision, and other relevant factors to provide personalized guidance.
Correct Answer is B
Explanation
Choice A Reason:
Confirming the newborn's Apgar score is important for assessing the newborn's overall condition, but it may not be the first priority.
Choice B Reason:
Verifying the newborn's identification is appropriate. Ensuring accurate identification is a crucial step in newborn care to prevent errors and ensure that interventions are carried out on the correct infant.
Choice C Reason:
Administering vitamin K is a standard practice but can wait until after the newborn's identification is confirmed.
Choice D Reason:
Determining obstetrical risk factors is part of the overall assessment but is not the immediate priority in this situation.
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