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 B

Explanation

Choice A rationale:

Abdominal distention is not a common side effect of opioids in newborns.

Choice B rationale:

Respiratory depression is a known side effect of opioid use, and newborns are particularly susceptible.

Choice C rationale:

Hyperreflexia is not typically associated with opioid use.

Choice D rationale:

Urinary retention is not a common side effect of opioids in newborns.

A. Butorphanol. B. Promethazine. C. Fentanyl. D. Naloxone.

Correct Answer is D

Explanation

Answer and explanation

Choice A rationale:

Butorphanol is an opioid agonist-antagonist. It would not be the first choice to treat opioid-induced respiratory depression because it can also cause respiratory depression.

Choice B rationale:

Promethazine is an antihistamine that has sedative effects and could potentially worsen respiratory depression.

Choice C rationale:

Fentanyl is a potent opioid and would likely exacerbate respiratory depression.

Choice D rationale:

Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect?

Correct Answer is B

Explanation

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Correct Answer is D

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.