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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A rationale:
Dysuria is not typically associated with lightening.
Choice B rationale:
Urinary frequency can increase when lightening occurs because the baby drops into the pelvis, putting more pressure on the bladder.
Choice C rationale:
Constipation is not typically associated with lightening.
Choice D rationale:
Dyspnea can actually improve when lightening occurs because there is less pressure on the diaphragm.
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