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 D

Explanation

Choice A rationale:

The face as the presenting part is not indicated by LSA. LSA stands for Left Sacrum Anterior, which indicates the baby’s position in the womb.

Choice B rationale:

The shoulder as the presenting part is not indicated by LSA. LSA refers to the baby’s position, not the presenting part.

Choice C rationale:

The occiput as the presenting part is not indicated by LSA. LSA refers to the baby’s position, not the presenting part.

Choice D rationale:

The buttocks as the presenting part is indicated by LSA. LSA (Left Sacrum Anterior) means the baby’s sacrum (buttocks) is presenting, and it is oriented to the mother’s left side and is facing forward (anterior).

A. 3 1 2 2 3. B. 3 2 1 0 3. C. 4 1 1 1 3. D. 4 2 1 3 1.

Correct Answer is D

Explanation

Choice A rationale:

This choice indicates 3 pregnancies, 1 term, 2 preterm, 2 living children, and 3 abortions. However, the client has had 4 pregnancies (twins, a son, and a miscarriage), so this choice is incorrect.

Choice B rationale:

This choice indicates 3 pregnancies, 2 term, 1 preterm, no living children, and 3 abortions. The client has 3 living children (twins and a son), so this choice is incorrect.

Choice C rationale:

This choice indicates 4 pregnancies, 1 term, 1 preterm, 1 living child, and 3 abortions. The client has 3 living children (twins and a son), so this choice is incorrect.

Choice D rationale:

This choice indicates 4 pregnancies, 2 term, 1 preterm, 3 living children, and 1 abortion. This correctly reflects the client’s obstetric history.

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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

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Correct Answer is D

Explanation

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.