Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in:
Select one:

Latent phase of the first stage of labor.

Transition phase of the first stage of labor.

Perineal phase of the second stage of labor.

Active phase of the first stage of labor.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Latent phase of the first stage of labor. This is because this phase is characterized by mild and irregular contractions, slow cervical dilation (up to 4 cm), minimal cervical eﬀacement (up to 40%), and minimal discomfort or pain. The latent phase is also known as the early phase or preparatory phase of labor.

Choice B Reason: Transition phase of the first stage of labor. This is an incorrect answer that describes a diﬀerent phase with diﬀerent characteristics. The transition phase is marked by strong and frequent contractions, rapid cervical dilation (from 8 to 10 cm), complete cervical eﬀacement (100%), and intense discomfort or pain. The transition phase is also known as the terminal phase or acceleration phase of labor.

Choice C Reason: Perineal phase of the second stage of labor. This is an incorrect answer that refers to another stage and phase with diﬀerent features. The second stage of labor begins with complete cervical dilation (10 cm) and ends with delivery of the baby. The perineal phase is the last part of the second stage, where the baby's head crowns and emerges through the vaginal opening.

Choice D Reason: Active phase of the first stage of labor. This is an incorrect answer that indicates another phase with diﬀerent atributes. The active phase is characterized by moderate and regular contractions, progressive cervical dilation (from 4 to 8 cm), increased cervical eﬀacement (from 40% to 80%), and increased discomfort or pain. The active phase is also known as the middle phase or dilatation phase of labor.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason: "You would have seen more symptoms if you had been looking more closely at your baby." This is an inappropriate response that blames the parents for missing the signs of sepsis and does not explain the Reason for the subtle symptoms.

Choice B Reason: "A newborn's immune system isn't mature, so symptoms are subtle and can be hard to recognize." This is an appropriate response that educates the parents about the immunological basis of sepsis in newborns and reassures them that they are not at fault for not noticing the symptoms.

Choice C Reason: "A high fever will always be present in sick newborns, including your baby." This is an incorrect response that contradicts the fact that newborns may not develop fever in response to infection due to their immature immune systems.

Choice D Reason: "A mother's immunity usually protects the infant from illness, but not in this case." This is an inaccurate response that implies that the mother failed to provide adequate immunity to her baby and does not address the question of why the baby did not seem very ill.

A. Grunting and nasal ﬂaring. B. Acrocyanosis. C. Abdominal breathing. D. Respiratory rate of 54 breaths/minute.

Correct Answer is A

Explanation

Choice A Reason: Grunting and nasal ﬂaring. These are signs of respiratory distress in newborns, which indicate that their oxygenation needs are not being met. Grunting and nasal ﬂaring. This is because grunting and nasal ﬂaring are signs of respiratory distress in newborns, which indicate inadequate oxygenation and ventilation. Grunting is a noise made by the newborn when exhaling, which reﬂects an atempt to keep the alveoli open and increase lung volume.

Nasal ﬂaring is a widening of the nostrils when inhaling, which reﬂects an eﬀort to reduce airway resistance and increase airﬂow.

Choice B Reason: Acrocyanosis. This is not a sign of respiratory distress in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not aﬀect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.

Choice C Reason: Abdominal breathing. This is not a sign of respiratory distress in newborns, but rather a normal patern of breathing for them. Abdominal breathing means that the newborn's abdomen rises and falls with each breath, which reﬂects the use of the diaphragm as the primary respiratory muscle.

Choice D Reason: Respiratory rate of 54 breaths/minute. This is not a sign of respiratory distress in newborns, but rather a normal range of respiratory rate for them. A normal respiratory rate for a newborn ranges from 40 to 60 breaths per minute.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in: Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parents of a newborn who is being treated for bacterial septicemia ask the nurse why their baby didn't seem very ill. The best response of the nurse is: Select one:

Correct Answer is B

Explanation

The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygenation needs are not being met? Select one:

Correct Answer is A

Explanation

After the birth of a newborn, the nursing intervention that most eﬀectively promotes parental atachment is: Select one:

A woman has just entered the third stage of labor. The nurse would focus care on which of the following? Select one:

The nurse at a shelter is counseling a group of women experiencing domestic violence. What is most important for the nurse to emphasize? Select one:

If a woman has a pre-existing condition of diabetes, the nurse knows that she would be at risk for what symptom(s) during her pregnancy? Select one:

The nurse is performing a newborn physical assessment and is about to elicit the Moro reﬂex. Which of the following responses should the nurse expect to see? Select one:

The nurse's initial action when caring for an otherwise stable, full term infant with a slightly decreased temperature is to: Select one:

The patient is 34 weeks pregnant and during a regular prenatal visit she asks how to do kick counts. The best response by the nurse would be: Select one:

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? Select one:

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in:
Select one: