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.

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Correct Answer is B

Explanation

Choice A Reason: "If I try to talk to my partner during a contraction, I can't." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor is a condition where there are regular and painful uterine contractions that cause cervical dilation and eﬀacement, and lead to delivery of the baby and placenta. True labor contractions are usually strong and consistent, and they tend to increase or persist with activity or position changes. True labor contractions can be so intense that they interfere with speech or breathing.

Choice B Reason: ) "My contractions slow down when I walk around." This is because this statement by the client would lead the nurse to suspect that the woman is experiencing false labor, which is also known as Braxton Hicks contractions or practice contractions. False labor is a condition where there are irregular and painless uterine contractions that do not cause cervical dilation or eﬀacement. False labor can occur throughout pregnancy, but it becomes more noticeable and frequent in late pregnancy. False labor contractions are usually weak and inconsistent, and they tend to decrease or stop with activity or position changes.

Choice C Reason: "I feel contractions start mostly in my back and they sweep around to the top of my abdomen." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor contractions usually start in the lower back and radiate to the lower abdomen or groin, following a wave-like patern. False labor contractions are more likely to be felt in the upper abdomen or sides, without a clear patern.

Choice D Reason: "My contractions are about 6 minutes apart and regular." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor contractions usually have a regular frequency and duration, and they become closer and longer as labor progresses. False labor contractions are more likely to have an irregular frequency and duration, and they do not change significantly over time.

A. Vascular spider veins. B. Linea nigra. C. Melasma. D. Striae gravidarum.

Correct Answer is B

Explanation

Choice A Reason: Vascular spider veins. This is an incorrect answer that refers to a diﬀerent skin change that occurs during pregnancy, which aﬀects the blood vessels, not the pigment. Vascular spider veins are small red or purple clusters of blood vessels that appear on the skin, especially on the face, neck, chest, or legs. Vascular spider veins are caused by increased blood volume and hormonal changes, which dilate and rupture the capillaries. Vascular spider veins are harmless and usually disappear after delivery.

Choice B Reason: Linea nigra. This is because linea nigra is a term that refers to a darkened vertical line that appears on the abdomen during pregnancy, which runs from the umbilicus to the pubis. Linea nigra is caused by increased production of melanin, which is a pigment that gives color to the skin and hair. Linea nigra is more common and noticeable in women with darker skin tones, and it usually fades after delivery.

Choice C Reason: Melasma. This is an incorrect answer that refers to a diﬀerent skin change that occurs during pregnancy, which aﬀects the pigment, but not in a linear patern. Melasma is a term that refers to patches of brown or gray-brown discoloration that appear on the face, especially on the forehead, cheeks, nose, or upper lip. Melasma is also caused by increased production of melanin, but it is inﬂuenced by sun exposure and genetic factors. Melasma is also known as chloasma or the mask of pregnancy, and it may persist after delivery.

Choice D Reason: Striae gravidarum. This is an incorrect answer that refers to a diﬀerent skin change that occurs during pregnancy, which aﬀects the connective tissue, not the pigment. Striae gravidarum are stretch marks that appear on the skin, especially on the abdomen, breasts, hips, or thighs. Striae gravidarum are caused by rapid growth and stretching of the skin, which damage the collagen and elastin fibers. Striae gravidarum are initially red or purple, but they fade to white or silver after delivery.

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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:

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Naxlex Comprehensive Predictor Exams

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? Select one:

Correct Answer is B

Explanation

Assessment of a pregnant woman reveals a pigmented vertical line between the umbilicus and the pubis. The nurse documents this finding as: Select one:

Correct Answer is B

Explanation

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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: