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?

The correct answer is choice A.

Choice A rationale:

The glucose challenge test is used to check for gestational diabetes during pregnancy. People at average risk of gestational diabetes usually have this test done during the second trimester, generally between 24 and 28 weeks of pregnancy.

Choice B rationale:

This is too early in the pregnancy to screen for gestational diabetes. The body’s response to sugar changes as the pregnancy progresses, so testing is typically done later.

Choice C rationale:

This is still a bit early for the screening. The recommended time is between 24 and 28 weeks of gestation.

Choice D rationale:

This is too late in the pregnancy for the screening. The recommended time is between 24 and 28 weeks of gestation.

The correct answer is choice D.

Choice A rationale:

Superficial structures above the muscle refer to first-degree lacerations, which only involve the skin of the perineum and vaginal mucosa.

Choice B rationale:

A fourth-degree laceration does not stop at the anterior rectal wall. It extends through the anal sphincter and into the rectal mucosa.

Choice C rationale:

While a fourth-degree laceration does involve the anal sphincter muscle, it also includes the underlying rectal mucosa.

Choice D rationale:

A fourth-degree laceration involves the perineal muscles, the anal sphincter, and the underlying rectal mucosa.