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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 C

Explanation

The correct answer is choice C.

Choice A rationale:

While it’s true that breastfed infants may lose 5% to 10% of their birth weight in the first few days, this is not exclusive to breastfed infants.

Choice B rationale:

Formula-fed babies may gain weight more quickly than breastfed babies, but they do not typically show an increase in weight by day 3.

Choice C rationale:

Both formula-fed and breastfed newborns can lose 5% to 10% of their birth weight in the first few days.

Choice D rationale:

While formula-fed newborns may gain weight more quickly than breastfed newborns, they do not typically gain 3% to 5% of the initial birth weight in the first 48 hours.

A. Assess the newborn's glucose level. B. Swaddle the infant and place in the bassinet. C. Dry the newborn and place it skin-to-skin on mother. D. Complete a full head-to-toe assessment.

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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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

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Correct Answer is C

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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?