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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 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.

A. "I should keep my baby's head covered.” B. "My baby's bassinet should be kept away from fans and air conditioning.” C. "My baby's temperature will be checked rectally every hour.” D. "I should place my baby on my stomach and cover her with a warm blanket.”

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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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin.The nurse should verify which of the following prior to administration?.

Correct Answer is D

Explanation

A nurse is providing teaching about newborn care to a client who is 2 hr postpartum.Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

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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?