The nurse is assessing a patient in the active phase of labor. What should the nurse expect during this phase?

Correct Answer: C

Rationale: The correct answer is C because during the active phase of labor, the cervix dilates from 4 to 7 centimeters, and the patient typically experiences the urge to push as the baby descends further down the birth canal. This indicates progress in labor and readiness for the second stage. Choices A, B, and D are incorrect as they do not specifically align with the characteristics of the active phase of labor. Choice A is not necessarily indicative of the active phase, choice B may happen at any stage of labor, and choice D is more characteristic of transition phase rather than the active phase.

Correct Answer: B

Rationale: The correct answer is B: Notify the health care provider. In the case of a transverse lie, the fetus is positioned sideways in the uterus, which can lead to complications during labor. Notifying the health care provider is crucial as they will need to assess the situation and determine the appropriate course of action, such as attempting to manually rotate the fetus or preparing for a cesarean section if necessary. Performing a vaginal exam (choice A) may not be safe or effective in this situation. Initiating parenteral therapy (choice C) and applying oxygen (choice D) are not the priority interventions in the case of a transverse lie.

Correct Answer: D

Rationale: The correct answer is D: pattern of uterine contractions. This is because the pattern of contractions is a key indicator of true labor. True labor contractions are regular, increasing in frequency, duration, and intensity. Assessing the pattern helps differentiate true labor from false labor. A: Cervical dilation is important but may not necessarily indicate true labor as it can occur in false labor as well. B: The amount of bloody show is a sign of cervical changes, but it alone does not confirm true labor. C: Fetal position and station are important for labor progress but do not definitively confirm true labor. In summary, assessing the pattern of uterine contractions is crucial in determining true labor as it provides direct insight into the progression and intensity of contractions, distinguishing it from false labor.

Correct Answer: A

Rationale: The correct answer is A because the patient's irregular contraction pattern and varying duration indicate early labor. By asking the patient about the contraction pattern, the nurse can assess the progression of labor and provide appropriate guidance. Choice B is incorrect because if the patient's membranes have ruptured, she would most likely feel a gush of fluid rather than just feeling wet. Choice C is incorrect as bloody show is not typically a reliable indicator of early labor. Choice D is incorrect as it does not address the need to assess the contraction pattern for progression of labor.

Correct Answer: A

Rationale: The correct answer is A because offering the patient a warm blanket helps prevent hypothermia, which can occur due to heat loss during the delivery process. This intervention promotes patient comfort and helps maintain their body temperature. Choice B is incorrect because placing an ice pack on the perineum is typically done in the immediate postpartum period to reduce swelling and discomfort, not during the fourth stage of labor. Choice C is incorrect because massaging the uterus if it is boggy is a postpartum intervention to prevent or treat uterine atony, not typically performed during the fourth stage of labor. Choice D is incorrect because delaying breastfeeding until the patient is rested is not necessary during the fourth stage of labor. Breastfeeding should be initiated as soon as possible after delivery to promote bonding and stimulate milk production.