Via vaginal examination, the nurse evaluates the woman to be 4 cm ...

[bcretired]

Via vaginal examination, the nurse evaluates the woman to be 4 cm dilated, with uterine contractions every 3 to 4 minutes by external fetal monitor. The nurse would report this as:
 
  1. first stage, latent phase.
  2. first stage, active phase.
  3. first stage, transition phase.
  4. second stage, latent phase.

Question 2

The nurse knows that the second stage of labor, the descent phase, has begun when the:
 
  1. amniotic membranes rupture.
  2. cervix cannot be felt during a vaginal examination.
  3. woman experiences a strong urge to bear down.
  4. presenting part is below the ischial spines.

[johnpizzaz]

Answer to Question 1

2
1. Incorrect. During the latent phase of the first stage of labor, the expected maternal progress is 0 to 3 cm dilated with contractions occurring every 5 to 30 minutes.
2. Correct. This maternal progress indicates that the woman is in the active phase of the first stage of labor.
3. Incorrect. During the transition phase of the first stage of labor, the expected maternal progress is 8 to 10 cm dilated with contractions occurring every 2 to 3 minutes.
4. Incorrect. During the latent phase of the second stage of labor, the woman would be completely dilated and experience a restful period of laboring down..

Answer to Question 2

3
1. Incorrect. Rupture of membranes has no significance in determining the stage of labor.
2. Incorrect. The second stage of labor begins with full cervical dilation.
3. Correct. During the descent phase of the second stage of labor, the woman may expe-rience an increase in the urge to bear down.
4. Incorrect. Many women may have an urge to bear down when the presenting part is be-low the level of the ischial spines. This can occur during the first stage of labor as early as 5 cm dilation.

[bcretired]

TYSM

[amandalm]

Thanks for the timely response, appreciate it