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.

Cervical effacement of 30%.

Strong desire to push.

Contractions every 90 seconds.

Cervical dilation of 6 cm.

Contractions every 2 to 3 minutes

Answer and Explanation

Correct Answer : D,E

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.

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Correct Answer is A

Explanation

Choice A rationale:

-2 station means the baby’s head is 2 cm above the ischial spines. This is a possible position during labor.

Choice B rationale:

0 station means the baby’s head is at the level of the ischial spines, which typically indicates the beginning of active labor.

Choice C rationale:

Crowning refers to when the baby’s head is visible at the vaginal opening, which occurs later in labor.

Choice D rationale:

+2 station means the baby’s head is 2 cm below the ischial spines. This typically occurs later in labor.

A. -2. B. +1. C. 0. D. -1. E. -1.

Correct Answer is C

Explanation

Choice A rationale:

Station -2 means the presenting part is 2 cm above the ischial spines. Engagement usually occurs at 0 station.

Choice B rationale:

Station +1 means the presenting part is 1 cm below the ischial spines. This usually occurs during labor, not necessarily at engagement.

Choice C rationale:

Station 0 means the presenting part is at the level of the ischial spines. This is typically when engagement occurs.

Choice D rationale:

Station -1 means the presenting part is 1 cm above the ischial spines. Engagement usually occurs at 0 station.

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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.

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Naxlex Comprehensive Predictor Exams

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as

Correct Answer is A

Explanation

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station?.

Correct Answer is C

Explanation

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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.