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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
While antidepressants can be an effective treatment for postpartum depression, it is not the priority action. The priority is to ensure the safety of the mother and the baby.
Choice B rationale:
Reinforcing postpartum and newborn care discharge teaching is important, but it is not the priority action when a client is showing signs of postpartum depression.
Choice C rationale:
Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action when a client is showing signs of postpartum depression.
Choice D rationale:
The priority action when a client is showing signs of postpartum depression is to assess for suicidal ideation or thoughts of harming herself or her baby. This is because postpartum depression can lead to thoughts of self-harm or harm to the baby, and immediate intervention is necessary to ensure the safety of both the mother and the baby.
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