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

Explanation

Choice A Reason:

Applying sacral counterpressure is appropriate. In the right occiput posterior position, the fetal head is positioned towards the mother's back, leading to increased pressure on the sacral are

A. Applying sacral counterpressure can help alleviate back pain during contractions.

Choice B Reason:

Performing transcutaneous electrical nerve stimulation (TENS) is inappropriate. While TENS can be used for pain relief in labor, applying sacral counterpressure is a more specific intervention for back pain related to fetal positioning.

Choice C Reason:

Initiating slow-paced breathing is inappropriate. While slow-paced breathing is a coping mechanism during contractions, it may not specifically address the back pain associated with the fetus in the right occiput posterior position.

Choice D Reason:

Assisting with biofeedback is inappropriate. Biofeedback is not a standard intervention for managing back pain during labor, especially in the context of fetal positioning. Sacral counterpressure is a more direct approach for this situation.

A. "The nurse will carry your newborn to the nursery for procedures." B. "We will document the relationship of visitors in your medical record. C. "Your baby will stay in the nursery while you are asleep." D. "Stall members who take care of your baby will be wearing a photo identification badge."

Correct Answer is D

Explanation

Choice A Reason:
"The nurse will carry your newborn to the nursery for procedures. "This statement is inappropriate. In current practice, there is an emphasis on family-centered care, and parents are often encouraged to be involved in the care of their newborns, including accompanying them for procedures whenever possible.

Choice B Reason:
"We will document the relationship of visitors in your medical record." This statement is inappropriate. While it is important to monitor and document visitors, the primary focus here is on healthcare staff and their identification.

Choice C Reason:
"Your baby will stay in the nursery while you are asleep." This statement is inappropriate. Promoting rooming-in and encouraging parental involvement in newborn care is a common practice to support bonding and breastfeeding, so this statement may not align with current best practices.

Choice D Reason:
"Staff members who take care of your baby will be wearing a photo identification badge." This statement reassures the client that the healthcare providers involved in the care of the newborn will have proper identification, enhancing security and ensuring that authorized personnel are handling the infant.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration?

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse Include in the plan of care for lactation suppression?

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not. Which of the following should the nurse recognize as a sign of true labor?

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin?

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?