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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Brownish vaginal discharge may indicate the presence of old blood or mucus and is not necessarily a cause for concern in the absence of other signs or symptoms.
B. Contractions occurring every 4 to 5 minutes are within the normal frequency range during the first stage of labor.
C. Pink mucoid vaginal discharge, also known as the "bloody show," is a common occurrence in early labor and is not typically a cause for immediate concern.
D. Contractions lasting 100 seconds are excessively long and are a cause for concern.
Prolonged contractions can lead to decreased uterine blood flow, impacting fetal oxygenation. Such prolonged contractions should be assessed and addressed promptly.
Correct Answer is C
Explanation
Choice A Reason:
Placing the client in a supine position for 30 minutes following the first dose of anesthetic solution is not a standard recommendation. The positioning during epidural placement is typically a seated or side-lying position.
Choice B Reason:
Administering 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution is not a standard practice for epidural anesthesi
A. Fluids may be administered, but the type and volume depend on the patient's individual needs and the healthcare provider's orders.
Choice C Reason:
Monitoring the client's blood pressure every minute following the first dose of anesthetic solution is appropriate. Epidural anesthesia can potentially cause hypotension (low blood pressure), which is a common side effect. Therefore, close monitoring of the client's blood pressure is crucial, especially following the administration of the initial dose of the anesthetic solution. The goal is to promptly detect and manage any decrease in blood pressure to ensure the well-being of both the mother and the baby.
Choice D Reason:
Ensuring the client has been NPO (nothing by mouth) for 4 hours prior to the placement of the epidural and the first dose of anesthetic solution is not a specific requirement for epidural anesthesi
A. NPO status is more relevant to surgical procedures involving general anesthesia and is not typically a strict requirement for epidural placement.
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