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:

Dysuria is not typically associated with lightening.

Choice B rationale:

Urinary frequency can increase when lightening occurs because the baby drops into the pelvis, putting more pressure on the bladder.

Choice C rationale:

Constipation is not typically associated with lightening.

Choice D rationale:

Dyspnea can actually improve when lightening occurs because there is less pressure on the diaphragm.

A. LOP. B. ROA. C. LOA. D. ROP.

Correct Answer is B

Explanation

Answer and explanation

Choice A rationale:

LOP (Left Occiput Posterior) would mean the baby’s occiput is towards the mother’s left and facing posteriorly, which is not the case here.

Choice B rationale:

ROA (Right Occiput Anterior) would mean the baby’s occiput is towards the mother’s right and facing anteriorly, which matches the description.

Choice C rationale:

LOA (Left Occiput Anterior) would mean the baby’s occiput is towards the mother’s left and facing anteriorly, which is not the case here.

Choice D rationale:

ROP (Right Occiput Posterior) would mean the baby’s occiput is towards the mother’s right and facing posteriorly, which is not the case here.

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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

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Correct Answer is B

Explanation

Correct Answer is B

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.