A pregnant client arrives at the health care facility, stating that her bed linens were wet
when she woke up this morning. She says no fluid is leaking but complains of mild
abdominal cramps and lower back discomfort. Vaginal examination reveals cervical
dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the
nurse concludes that the client is in which phase of the first stage of labor?
You Selected:
Latent phase
Correct response:
Latent phase
Explanation:
The latent phase of the first stage of labor is associated with irregular, short, mild
contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back
discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense
contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent
continues throughout the active phase and into the transitional phase, when the cervix
dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur
every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase.
Remediation:
Question 2 See full question
Which behavior should cause the nurse to suspect that a client's labor is moving quickly
and that the physician should be notified?
You Selected:
An increase in fetal heart rate variability
Correct response:
An increased sense of rectal pressure
Explanation:
An increased sense of rectal pressure indicates that the client is moving into the second
stage of labor. The nurse should be able to discern that information by the client's
,behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate
variability, and nausea and vomiting don't usually occur.
Remediation:
Question 3 See full question
A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's
partner is the health care surrogate for the client and her fetus. The sperm donor, who is
their best friend, has waived parental rights. If the client can't make health care
decisions for the fetus, who's responsible for making them?
You Selected:
The client's partner
Correct response:
The client's partner
Explanation:
Remediation:
Question 4 See full question
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated
and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to
6 minutes. Which intervention should the nurse recommend at this time?
You Selected:
lying in the left lateral recumbent position
Correct response:
walking around in the hallway
Explanation:
Most authorities suggest that a woman in an early stage of labor should be allowed to
walk if she wishes as long as no complications are present. Birthing centers and single-
room maternity units allow women considerable latitude without much supervision at
this stage of labor. Gravity and walking can assist the process of labor in some clients. If
the client becomes tired, she can rest in bed in the left lateral recumbent position or sit
in a comfortable chair. Resting in the left lateral recumbent position improves circulation
to the fetus.
Remediation:
Question 5 See full question
,While a 31-year-old multigravida at 39 weeks’ gestation in active labor is being
admitted, her amniotic membranes rupture spontaneously. The client’s cervix is 5 cm
dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is
reassuring. What should the nurse do first?
You Selected:
Auscultate the client's blood pressure.
Correct response:
Note the color, amount, and odor of the amniotic fluid.
Explanation:
The nurse’s first action when membranes rupture spontaneously is to check the odor,
consistency, and volume of the amniotic fluid. Because the fetal head is engaged and at
0 station, there is little likelihood of cord prolapse. However, when the fetal head is not
engaged, checking for cord prolapse would be the priority when the membranes rupture
spontaneously.
After rupture of the membranes, vaginal examinations should be kept to a minimum to
decrease the chance of infection.
Although auscultating the client’s blood pressure is important, it is not the priority
following spontaneous rupture of membranes.
Birth is not imminent if the client is 5 cm dilated. However, multigravid clients may
progress quickly in labor, especially after rupture of the membranes.
Remediation:
Question 6 See full question
A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial
actions by the nurse include:
You Selected:
perform sterile vaginal examination, increase IV fluids, and apply oxygen.
Correct response:
reposition the client, apply oxygen, and increase IV fluids.
Explanation:
Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency.
Interventions to improve perfusion include repositioning the client, oxygen, and IV fluids.
, A sterile vaginal exam is not indicated at this time. Late decelerations are not expected
findings and do not indicate an imminent birth.
Remediation:
Question 7 See full question
A client hospitalized for preterm labor tells the nurse her mother in law blames her for
"overdoing it" and causing the preterm labor. Which of the following is the most
appropriate response from the nurse?
You Selected:
“Let’s talk about how preterm labor occurs, so as to help you understand what
causes it.”
Correct response:
“Let’s talk about how preterm labor occurs, so as to help you understand what
causes it.”
Explanation:
Remediation:
Question 8 See full question
A couple arrives at the hospital stating that the client’s contractions started 3 hours ago.
As they are walking into the room, the client tells the nurse that this is their fifth baby.
What is the nurse’s first priority while performing the admission?
You Selected:
Review the client’s obstetrical history.
Correct response:
Assess the imminence of birth.
Explanation:
This is the client's fifth baby, and she has been in labor for 3 hours. Given that multipara
clients experience the stages of labor at a significantly faster rate than nullipara clients,
it is critical that the nurse assess for the imminence of birth. After this has been
established, the nurse will know how much time he/she has to review the obstetrical
history, assess the client’s coping skills, and ensure the presence of a support person
for the labor and birth.
Remediation:
Question 9 See full question
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