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:
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh negative.
Choice B rationale:
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh positive.
Choice C rationale:
Rho (D) immunoglobulin is not administered when the client is Rh positive and the newborn is Rh negative.
Choice D rationale:
Rho (D) immunoglobulin is administered when the client is Rh negative and the newborn is Rh positive. Therefore, this choice is correct.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Keeping the baby’s head covered helps to prevent heat loss, as newborns lose a significant amount of heat through their heads.
Choice B rationale:
Keeping the baby’s bassinet away from fans and air conditioning helps to maintain a stable body temperature.
Choice C rationale:
Newborns’ temperatures are typically checked every 3 to 4 hours, not every hour, and are usually done axillary, not rectally.
Choice D rationale:
Placing the baby on the mother’s stomach and covering her with a warm blanket promotes skin-to-skin contact and helps to maintain the baby’s body temperature.
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