A 28-year-old gravida 1, para 0 patient who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet;

Correct Answer: A

Rationale: The correct answer is A because the patient's irregular contraction pattern and timing indicate early labor. The nurse should ask about the frequency, duration, and intensity of contractions to assess progression. Choices B and C focus on specific signs of labor but do not address the need for continuous monitoring and assessment like choice A does. Choice D does not address the need to gather specific information about the contraction pattern to determine the appropriate next steps. Therefore, A is the correct choice as it directly addresses the patient's current situation and provides guidance on what information is necessary for appropriate triage.

Correct Answer: B

Rationale: The correct answer is B: Surge of energy. This is a sign of impending labor because some women experience a burst of energy as the body prepares for childbirth. Weight gain (A) is not a typical sign of impending labor, as weight gain usually occurs earlier in pregnancy. Increase in urinary frequency (C) is a common symptom throughout pregnancy and may not specifically indicate impending labor. Dyspnea (D), which is difficulty breathing, is not typically a sign of impending labor unless it is due to specific complications.

Correct Answer: C

Rationale: The correct answer is C: Anthropoid. An anthropoid pelvis is characterized by a long and narrow shape with an anteroposterior diameter greater than the transverse diameter. This type of pelvis resembles the pelvic structure of anthropoid (higher primates) mammals. The other choices are incorrect because: A: Platypelloid pelvis is flat and broad, not long and narrow. B: Android pelvis has a heart-shaped inlet with an android appearance, not a long and narrow shape. D: Gynecoid pelvis is rounded and wider with a transverse diameter greater than the anteroposterior diameter, opposite of the described characteristics.

Correct Answer: B

Rationale: The correct answer is B: Second stage. This stage of labor is characterized by full dilation of the cervix and ends with the delivery of the baby. The intense rectal pressure reported by the patient indicates that the baby is descending through the birth canal, which is a hallmark sign of the second stage. In contrast, the first stage, latent (choice A) is characterized by early labor contractions and cervical dilation up to 6 cm. The third stage (choice C) is the delivery of the placenta, and the fourth stage (choice D) is the immediate postpartum period. The key here is recognizing the specific symptom of intense rectal pressure, which aligns with the second stage of labor.

Correct Answer: A

Rationale: The correct answer is A: Every 15 minutes. This frequency is recommended for a low-risk multiparous client in active labor without risk factors. Intermittent auscultation every 15 minutes allows for adequate monitoring of fetal well-being while also promoting maternal autonomy and mobility. Choices B, C, and D are incorrect because they are either too frequent or too infrequent for a low-risk client in active labor. Every 5 minutes (B) may be excessive and disrupt the labor process, every 20 minutes (C) may not provide sufficient monitoring, and every 30 minutes (D) may not detect changes in fetal status promptly.