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 C

Explanation

Choice A Reason: Continuing to monitor and document fetal heart rate. This is an inadequate response that does not address the urgency of the situation or intervene to prevent fetal distress or demise.

Choice B Reason: Changing the mother's position to left lateral and giving oxygen by nasal cannula. This is a partial response that may improve maternal-fetal blood ﬂow and oxygenation, but it does not resolve the cord compression or facilitate delivery.

Choice C Reason: With a sterile glove, maintaining pressure to lift the presenting part and emergently notifying the provider for a STAT C-section. This is an appropriate response that aims to reduce the cord compression by elevating the fetal head away from the cord and prepare for an immediate cesarean delivery.

Choice D Reason: Bolusing the patient with 1000cc lactated ringers. This is an irrelevant response that does not address the cause of the problem or improve fetal outcome.

A. "If I go too long overdue, the amniotic ﬂuid volume can become too low for my baby to be safe." B. "My baby took longer to grow, and now she's ready to be born." C. "I don't really need this induction, my baby will come whenever he wants to." D. "Since I am so tired of being pregnant, I am being induced."

Correct Answer is A

Explanation

Choice A Reason: "If I go too long overdue, the amniotic ﬂuid volume can become too low for my baby to be safe." This is a correct answer that indicates that the client understands one of the Reasons for induction of labor at 42 weeks' pregnancy.

Choice B Reason: "My baby took longer to grow, and now she's ready to be born." This is an incorrect answer that shows a misconception about fetal growth and development. Fetal growth does not depend on gestational age alone, but also on genetic, maternal, placental, and environmental factors. A post-term fetus does not necessarily grow faster or larger than a term fetus. In fact, some post-term fetuses may experience intrauterine growth restriction (IUGR), which means slower than expected growth for gestational age.

Choice C Reason: "I don't really need this induction, my baby will come whenever he wants to." This is an incorrect answer that reveals a lack of awareness or acceptance of the need for induction of labor at 42 weeks' pregnancy. Induction of labor is recommended for post-term pregnancies to prevent potential complications such as fetal distress, stillbirth, or maternal hemorrhage.

Choice D Reason: "Since I am so tired of being pregnant, I am being induced." This is an incorrect answer that implies that induction of labor is based on maternal preference or convenience rather than medical indication. Induction of labor should not be done without a valid Reason or informed consent, as it carries some risks such as failed induction, prolonged labor, infection, uterine rupture, or cesarean 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

The nurse, working in labor and delivery, performs a sterile vaginal exam on a laboring woman. During the exam, she feels a loop of pulsating cord in the vagina. The nurse would anticipate: Select one:

Correct Answer is C

Explanation

The client at 42 weeks' pregnancy is admited for induction of her labor. Which statement indicates that she understands the Reasons for the induction? Select one:

Correct Answer is A

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: