Maternity Nursing: Antepartum Q 44
A nurse is caring for a client in labor. The nurse determines that the client is beginning in the second stage of labor when which of the following assessments is noted?
A. The client begins to expel clear vaginal fluid.
B. The contractions are regular.
C. The membranes have ruptured
D. The cervix is dilated completely.
Correct Answer: D. The cervix is dilated completely.
The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate. After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts. The fetus passes through the birth canal via 7 movements known as the cardinal movements.
Option A: The first stage of labor is further subdivided into two phases, which are defined by the degree of cervical dilation. The latent phase is commonly defined as the 0 to 6 cm, while the active phase commences from 6 cm to full cervical dilation.
Option B: Although precisely determining when labor starts may be inexact, labor is generally defined as beginning when contractions become strong and regularly spaced at approximately 3 to 5 minutes apart
Option C: Rupture of membranes results from a variety of factors that ultimately lead to accelerated membrane weakening. This is caused by an increase in local cytokines, an imbalance in the interaction between matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases, increased collagenase and protease activity, and other factors that can cause increased intrauterine pressure.