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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Manifestations of uteroplacental insufficiency. This is an incorrect answer that describes a different condition that affects the fetus, not the mother. Uteroplacental insufficiency is a condition where the placenta fails to deliver adequate oxygen and nutrients to the fetus, which can result in fetal growth restriction, distress, or demise. Uteroplacental insufficiency does not cause shortness of breath, hypoxia, or cyanosis in the mother.
Choice B Reason: Manifestations of prolapsed cord. This is an incorrect answer that refers to another condition that affects the fetus, not the mother. Prolapsed cord is a condition where the umbilical cord slips through the cervix before the baby and becomes compressed by the fetal head, which can reduce oxygen flow to the fetus. Prolapsed cord does not cause shortness of breath, hypoxia, or cyanosis in the mother.
Choice C Reason: Manifestations of anaphylactoid syndrome of pregnancy. This is because anaphylactoid syndrome of pregnancy, also known as amniotic fluid embolism, is a rare and fatal condition where amniotic fluid enters into the maternal bloodstream and causes an allergic reaction, which can lead to respiratory failure, cardiac arrest, coagulopathy, and coma. Anaphylactoid syndrome of pregnancy can occur during or after labor and delivery, especially in cases of NSVD, multiparity, advanced maternal age, or placental abruption.
Choice D Reason: Manifestations of an acute asthmatic episode. This is an incorrect answer that assumes that the mother has a history of asthma or an allergic trigger. Asthma is a chronic inflammatory disorder of the airways that causes wheezing, coughing, chest tightness, and dyspnea. Asthma can be exacerbated by pregnancy or labor, but it is not a common cause of sudden onset respiratory distress in the postpartum period.
Correct Answer is D
Explanation
Choice A Reason: Preterm infant. This is an incorrect answer that confuses TTN with another respiratory condition called respiratory distress syndrome (RDS). RDS is a serious condition where the newborn's lungs are immature and lack sufficient surfactant, which is a substance that reduces surface tension and prevents alveolar collapse. RDS can cause respiratory distress, hypoxia, acidosis, and organ failure. It is more common in preterm infants, especially those born before 37 weeks' gestation.
Choice B Reason: Female infant. This is an incorrect answer that has no evidence or rationale to support it. TTN does not have a gender preference or difference in incidence or severity.
Choice C Reason: GBS status of mother. This is an incorrect answer that relates to another respiratory complication called early-onset neonatal sepsis (EONS). EONS is a bacterial infection that occurs within 72 hours after birth, which can affect multiple organs and systems in the newborn. EONS can be caused by group B streptococcus (GBS), which is a common bacterium that colonizes in some women's vagina or rectum. GBS can be transmited to the newborn during delivery and cause pneumonia, meningitis, or septic shock.
Choice D Reason: Cesarean section. This is because cesarean section is a risk factor for TTN, which is a mild respiratory problem that results from delayed clearance of fetal lung fluid after birth. TTN causes rapid breathing, nasal flaring, grunting, and mild cyanosis. It usually resolves within 24 to 48 hours after birth. Cesarean section can increase the risk of TTN because it bypasses the normal process of labor, which helps squeeze out some of the fluid from the fetal lungs.
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