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 C
Explanation
Choice A rationale:
The back of the hand is sensitive to temperature, not pressure, making it less suitable for assessing contraction intensity.
Choice B rationale:
Finger tips are sensitive and can detect small changes, but they may not cover a large enough area to accurately assess contraction intensity.
Choice C rationale:
The palm of the hand covers a larger area and can better gauge the overall firmness of the uterus.
Choice D rationale:
Finger pads are sensitive to texture, not pressure, making them less suitable for this task.
Correct Answer is C
Explanation
Choice A rationale:
Contractions every 1 minute and cervical dilation of 9 cm are indicative of the transition phase of labor.
Choice B rationale:
Contractions every 2 1/2 minutes and cervical dilation of 8 cm are indicative of the active phase of labor.
Choice C rationale:
Contractions every 5 minutes and cervical dilation of 3 cm are indicative of the latent phase of labor.
Choice D rationale:
Contractions every 3 minutes and cervical dilation of 6 cm are indicative of the active phase of labor.
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