A nurse is assessing a primigravida client at 38 weeks gestation who is in active labor. Which assessment finding would indicate that the client is progressing normally through the first stage of labor?
1Contractions occurring every 8-10 minutes lasting 30 seconds with mild intensity
2Cervical dilation of 2 cm with 25% effacement and contractions every 15 minutes
3Contractions occurring every 3-4 minutes lasting 45-60 seconds with moderate to strong intensity✓ 정답
4Fetal heart rate baseline of 110 bpm with late decelerations noted during contractions
해설
Active labor involves regular, strong contractions every 3-5 minutes lasting 45-60 seconds. Option 3 matches this pattern, indicating normal progress. Other options show early labor or abnormal findings.
Clinical Judgment
This question assesses the ability to identify key assessment findings that indicate normal progression during the Active Phase of the first stage of labor in a primipara. The core concept is understanding the characteristics of effective uterine contractions. Active labor is the period when the cervix dilates from 4 to 7 cm, and inducing this requires contractions that are regular and of sufficient intensity. The contraction pattern in the correct answer, option 3 (every 3-4 minutes, lasting 45-60 seconds, moderate-to-strong intensity), accurately describes the optimal uterine activity needed to dilate the cervix and descend the fetus. The other options represent abnormal findings such as the latent phase, ineffective contractions, or fetal distress.
Memory Tip:
To remember the active labor contraction pattern, use the Active Labor 3-4-5-6Rule: 3-4 minute intervals, lasting 45-60 seconds, with cervical dilation of 4-6 cm (or 7 cm).
KR vs US:
While the term 'active phase' is commonly used in Korea, NGN/CJMM and US nursing standards emphasize a more detailed division of labor stages into Early Labor (latent phase), Active Labor, and Transition. For US exams, it is essential to know the precise normal ranges (contraction frequency, duration, and cervical dilation) for each of these three phases.
Clinical Practice Guide
During the active phase of the first stage of labor, nursing assessment must systematically evaluate contraction frequency (the time from the start of one contraction to the start of the next), duration, and intensity (the firmness of the uterus on palpation or the pressure during internal monitoring). In addition, cervical dilation, effacement, and fetal station should be assessed together to determine the true progress of labor.
Caution:
A common pitfall in SATA (Select All That Apply) questions is choosing an option based solely on cervical dilation measurements (e.g., 4 cm) as evidence of "labor progress." You must verify that an effective contraction pattern (such as the one in option 3) is also present. Cervical status alone cannot confirm active phase progression.
Active Labor (활동기 진통) — A stage of the first stage of labor, when the cervix dilates from 4 cm (or 6 cm) to 7 cm. It is characterized by regular, strong uterine contractions (every 3–5 minutes, lasting 45–60 seconds).
Cervical Dilation (자궁경부 개대) — The degree to which the cervix opens during labor. It is measured from 0 cm (closed) to 10 cm (fully dilated), and during the active phase, it progresses at a rate of about 1.2 cm or more per hour.
Uterine Contractions (자궁 수축) — Periodic contractions of the uterine muscles that occur for childbirth. They are assessed by frequency, duration, and intensity.
Late Decelerations (늦은 감속) — A deceleration of the fetal heart rate that begins when the uterine contraction is at its peak and persists after the contraction ends. It is a sign of uteroplacental insufficiency and must be reported immediately.
Primigravida (초산부) — A woman experiencing her first pregnancy. The time required for each stage of labor is generally longer than that of a woman who has given birth before.