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 C
Explanation
The correct answer is choice C.
Choice A rationale:
A 1-minute Apgar score of 5 points does not necessarily indicate a congenital heart defect or an immature respiratory system.
Choice B rationale:
An Apgar score of 5 points at 1 minute does not require immediate and aggressive interventions for survival.
Choice C rationale:
A 1-minute Apgar score of 5 points indicates that the infant is experiencing moderate difficulty in adjusting to extrauterine life.
Choice D rationale:
An Apgar score of 5 points at 1 minute does not indicate that the infant is adjusting well to extrauterine life.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
While it’s important to monitor a newborn’s glucose level, it’s not the immediate priority following birth.
Choice B rationale:
Placing the infant in the bassinet is not the immediate priority. The newborn needs to be dried and warmed first to prevent hypothermia.
Choice C rationale:
Drying the newborn and placing it skin-to-skin on the mother helps prevent hypothermia and promotes bonding. This is the immediate priority.
Choice D rationale:
A full head-to-toe assessment is important, but it’s not the immediate priority following birth.
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