ATI OBS EXAM 3 Complete Verified
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A client whose cervix is dilated to 5 cm is considered to be in which phase of labor?
a. Latent phase
b. Active phase
c. Second stage
d. Third stage
b. Active phase
The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The latent phase is
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from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor
begins when the cervix is completely dilated until the birth of the baby. The third stage of
labor is from the birth of the baby until the expulsion of the placenta.
The nurse is assessing a client in the active phase of labor. What should the nurse expect
during this phase?
a. The client is sociable and excited.
b. The client is requesting pain medication.
c. The client begins to experience the urge to push.
d. The client experiences loss of control and irritability.
b. The client is requesting pain medication.
During the active phase of labor, contraction intensity and discomfort increase to the point
where women often request pain medication. Sociability and excitability occur during the
latent phase. The urge to push occurs at the end of the transition phase or the second stage
of labor. Loss of control and irritability occur during the transition phase of labor.
A laboring client asks the nurse how she will know that the contraction is at its peak. The
nurse explains that the contraction peaks during which stage of measurement?
a. The acme
b. The interval
c. The increment
d. The decrement
a. The acme
The acme is the peak or period of greatest strength during the middle of a contraction cycle.
The interval is the period between the end of the contraction and the beginning of the next.
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The increment is the beginning of the contraction until it reaches the peak. The decrement
occurs after the peak until the contraction ends.
A client in labor presents with a breech presentation. The nurse understands that a breech
presentation is associated with:
a. more rapid labor.
b. a high risk of infection.
c. maternal perineal trauma.
d. umbilical cord compression.
d. umbilical cord compression.
The umbilical cord can compress between the fetal body and maternal pelvis when the body
has been born but the head remains within the pelvis. Breech presentation is not associated
with a more rapid labor. There is no higher risk of infection with a breech birth. There is no
higher risk for perineal trauma with a breech birth.
The primary difference between the labor of a nullipara and that of a multipara is:
a. total duration of labor.
b. level of pain experienced.
c. amount of cervical dilation.
d. sequence of labor mechanisms.
a. total duration of labor.
Multiparas usually labor more quickly than nulliparas, making the total duration of their
labor shorter. The level of pain is individual to the woman, not the number of labors she has
experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is
the same with all labors.
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Which maternal factor may inhibit fetal descent?
a. A full bladder
b. Decreased peristalsis
c. Rupture of membranes
d. Reduction in internal uterine size
a. A full bladder
A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the
fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes
will assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal
descent.
Which assessment finding would cause a concern for a client who had delivered vaginally?
a. Estimated blood loss (EBL) of 500 mL during the birth process
b. White blood cell count of 28,000 mm3 postbirth
c. Client complains of fingers tingling
d. Client complains of thirst
c. Client complains of fingers tingling
A clients complaint of fingers tingling may represent respiratory alkalosis due to
hyperventilation breathing patterns during labor. As such it requires intervention by the
nurse to have the client slow breathing down and restore normal carbon dioxide levels.
Which clinical findings would be considered to be normal for a preterm fetus during the
labor period?
a. Baseline tachycardia
b. Baseline bradycardia
c. Fetal anemia
d. Acidosis
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