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A nurse is caring for a pregnant client in labor in a health care facility.
The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?

Cervix dilation of 5 cm with 50% effacement.

Rupturing of fetal membranes.

Start of regular contractions.

Cervix dilation of 10 cm with 100% effacement.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D.

Choice A rationale:

Cervix dilation of 5 cm with 50% effacement is a sign of active phase of the first stage of labor, not the end of it.

Choice B rationale:

Rupturing of fetal membranes can occur at any time during labor, not specifically at the end of the first stage.

Choice C rationale:

Start of regular contractions is a sign of the onset of labor, not the end of the first stage.

Choice D rationale:

Cervix dilation of 10 cm with 100% effacement indicates the end of the first stage of labor and the beginning of the second stage.

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Correct Answer is B

Explanation

The correct answer is choice B.

Choice A rationale:

Brownish vaginal discharge can be a sign of labor but it is not definitive.

Choice B rationale:

Cervical dilation is a definitive sign that labor has started.

Choice C rationale:

Presence of amniotic fluid in the vaginal vault can indicate rupture of membranes but it does not confirm labor.

Choice D rationale:

Pain above the umbilicus is not a typical sign of labor.

A. She did her perineal care independently. B. She is eager to talk about her birth experience. C. She has not asked for anything for pain all day. D. She sits and rocks her infant for long intervals.

Correct Answer is A

Explanation

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

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A nurse is caring for a pregnant client in labor in a health care facility.The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?

Nursing Test Bank

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Correct Answer is A

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A nurse is caring for a pregnant client in labor in a health care facility.
The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?