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:

Offering fluids is important to prevent dehydration, but it’s not the priority during the fourth stage of labor.

Choice B rationale:

Encouraging the woman to void can help prevent urinary retention, but it’s not the priority.

Choice C rationale:

Assessing the uterine fundus is the priority during the fourth stage of labor. This is to ensure that the uterus is contracting and to prevent postpartum hemorrhage.

Choice D rationale:

Assisting with perineal care is important for comfort and hygiene, but it’s not the priority.

So, the correct answer is C, assessing the uterine fundus.

A. Sign of breast development. B. Sexual experience. C. Menstrual period. D. Full hormonal cycle.

Correct Answer is C

Explanation

Choice A rationale:

The first sign of breast development is not menarche. It is a part of puberty, but it is not the definition of menarche.

Choice B rationale:

A woman’s first sexual experience is not menarche. Menarche refers to a specific biological event.

Choice C rationale:

Menarche is defined as a woman’s first menstrual period. This is the correct definition.

Choice D rationale:

A full hormonal cycle is not menarche. While the hormonal cycle is related to menstruation, it is not the definition of menarche.

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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

Which action is a priority when caring for a woman during the fourth stage of labor?.

Correct Answer is C

Explanation

After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first:.

Correct Answer is C

Explanation

A nurse is providing care to a woman in labor. After the assessment of the fetus, the nurse documents the fetal lie. Which term would the nurse use?

A nurse palpates a woman's fundus to determine contraction intensity. What would be most appropriate for the nurse to use for palpation?.

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?.

The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part?.

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?.

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?.

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.