Difficulty: Medium
Average Score: 87%
Simulated
For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for:
Correct answer
A
Rationale
Prolonged latent phase (8 hours) in a primigravid client can lead to maternal exhaustion due to sustained effort and lack of progress, impacting labor stamina. Chills/fever, fluid overload, or meconium-stained fluid are less likely without specific risk factors.