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 C

Explanation

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.

A. Cephalhematoma. B. Vertex presentation. C. Caput Succedaneum. D. Molding.

Correct Answer is D

Explanation

Choice A rationale:

A cephalhematoma is a collection of blood that can occur under the scalp of a newborn. It does not aid in the passage of the fetal skull through the birth canal.

Choice B rationale:

Vertex presentation refers to the position of the fetus in the womb, not a feature of the skull that aids in birth.

Choice C rationale:

Caput succedaneum is a swelling of the scalp in a newborn. It is caused by pressure from the uterus or vaginal wall during a head-first (vertex) delivery, not a feature that aids in birth.

Choice D rationale:

Molding refers to the shaping of the fetal skull to fit through the birth canal. This is possible due to the presence of sutures and fontanelles in the skull, which allow the bony plates of the skull to move and overlap.

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

Correct Answer is C

Explanation

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

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.