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A nurse is assessing a woman in labor.
Which finding would the nurse identify as a cause for concern during a contraction?.

Blood pressure rise from 110/60 mm Hg to 120/74.

White blood cell count of 12,000 cells/mm.

Respiratory rate of 10 breaths/minute.

Heart rate increase from 76 bpm to 90 bpm.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A slight increase in blood pressure during contractions is normal.

Choice B rationale:

A white blood cell count of 12,000 cells/mm is within the normal range.

Choice C rationale:

A respiratory rate of 10 breaths/minute is low and could indicate respiratory depression.

Choice D rationale:

A heart rate increase from 76 bpm to 90 bpm is within the normal range.

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Correct Answer is ["D","E"]

Explanation

Choice A rationale:

Cervical effacement of 30% is more indicative of the early phase of labor, not the active phase. In the active phase, effacement is usually 80-100%.

Choice B rationale:

A strong desire to push is usually associated with the transition phase of labor, not the active phase.

Choice C rationale:

Contractions every 90 seconds could be indicative of the active phase, but this can vary between individuals.

Choice D rationale:

Cervical dilation of 6 cm is indeed indicative of the active phase of labor, which is typically characterized by cervical dilation of 4-7 cm.

Choice E rationale:

Contractions every 2 to 3 minutes are common in the active phase of labor.

A. Vagina. B. Pelvic inlet. C. Pelvic outlet. D. Mid pelvis. E. Pelvic Floor Muscles. F. Cervix.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

The vagina is not part of the true pelvis. It is the canal that leads from the uterus to the exterior of the body.

Choice B rationale:

The pelvic inlet is the upper part of the lesser pelvis where the baby’s head engages during labor. It is part of the true pelvis.

Choice C rationale:

The pelvic outlet is the lower opening of the pelvis. It is part of the true pelvis.

Choice D rationale:

The mid pelvis is the part of the pelvis where the baby turns to get into the right position for birth. It is part of the true pelvis.

Choice E rationale:

The pelvic floor muscles support the pelvic organs and help in the process of childbirth. They are part of the true pelvis.

Choice F rationale:

The cervix is the lower part of the uterus that opens into the vagina. It is not part of the true pelvis. So, the correct answers are B, C, D, and E.

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A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction?.

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Naxlex Comprehensive Predictor Exams

A nurse is providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment findings? Select all that apply.

Correct Answer is ["D","E"]

Explanation

Correct Answer is ["B","C","D","E"]

Explanation

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A nurse is assessing a woman in labor.
Which finding would the nurse identify as a cause for concern during a contraction?.