Elsevier NCLEX Exam Practice Question of the Week: NCLEX Exam Practice Question of the Week

Elsevier NCLEX Exam Review

Question: A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of the following assessments is noted?
1. The contractions are regular.
2. The membranes have ruptured.
3. The cervix is dilated completely.
4. The client begins to expel clear vaginal fluid.

Answer: 3

Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.
Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they are comparable or alike. From the remaining options, recalling that regular contractions occur before the second stage of labor will direct you to option 3. Review the stages of labor if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process-Assessment
Content Area: Maternity-Intrapartum
Reference: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child nursing care (4th ed., p. 466). St. Louis: Mosby.

This week’s NCLEX exam practice question came from:

Silvestri: Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition , Chapter 26, page 307, question 250

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