A primigravida client at 39 weeks gestation is admitted to the labor and delivery unit. During the initial assessment, which finding would be the most important indicator that the client is in active labor?

Cervical dilation of 4 cm with 80% effacement indicates active labor, defined by progressive cervical changes. Other options represent early labor or normal findings not specific to active phase.

Core Nursing Explanation This question tests the critical nursing skill of differentiating the stages of labor, specifically identifying the definitive sign of the Active phase of the first stage of labor. Labor is a dynamic process, and accurate assessment is essential for safe management and setting appropriate patient expectations. Key Concept Analysis The core theme is identifying the Key Point! objective, measurable criterion that defines the transition from latent (early) labor to active labor. According to standard obstetric definitions, active labor begins when the cervix is dilated to approximately 4-6 cm (with 4 cm being a widely accepted threshold) and contractions become regular, longer, and stronger. Cervical effacement (thinning) and dilation (opening) are the primary indicators of true, progressive labor. Answer Rationale Option ③ is correct because Cervical dilation of 4 cm with 80% effacement meets the classic definition for the onset of the active phase. This signifies that labor has progressed beyond the preparatory latent phase and into the phase of more rapid cervical change. This finding requires the nurse to prepare for more frequent assessments, consider pain management options, and anticipate more rapid progression toward delivery. Distractor Analysis Watch out for confusion! It's easy to be distracted by other signs of labor that are not definitive for the active phase.
Option ①: Contractions every 10 minutes lasting 30 seconds are characteristic of Latent (early) labor. Active labor contractions are typically 3-5 minutes apart, lasting 45-60 seconds, and are of moderate to strong intensity.
Option ②: Bloody show (passage of the mucus plug) and Rupture of membranes (ROM) can occur hours or even days before active labor begins. While significant events requiring assessment, they do not, by themselves, indicate the stage of labor.
Option ④: A fetal heart rate (FHR) of 140 beats per minute is within the normal range (110-160 bpm). It is a crucial parameter to monitor for fetal well-being throughout labor, but it does not provide any information about the progress or stage of labor. Related Concepts Understanding the complete picture of labor stages is vital. The first stage of labor (from onset of true labor to full cervical dilation) is divided into Latent and Active phases. The second stage is from full dilation to delivery of the baby, and the third stage is from delivery of the baby to delivery of the placenta. Nursing care priorities shift dramatically with each stage. Concept Summary

Labor Phase	Key Characteristics	Nursing Focus
Latent (Early) Phase	0-3 cm dilation. Mild, irregular contractions. Excited/anxious mood.	Encourage rest, hydration, comfort measures at home if possible.
Active Phase	4-7 cm dilation. Strong, regular contractions (q3-5 min). Increased focus.	Admit to hospital. Frequent assessments. Pain management. Support.
Transition Phase	8-10 cm dilation. Intense contractions (q2-3 min). Irritable/overwhelmed.	Constant coaching. Prepare for delivery. Avoid pushing until complete.

Side-by-Side Comparison!

Sign	Latent Labor	Active Labor
Contractions	Irregular, mild, >5 min apart, 임상 시나리오 Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in triage. Maria, a 39-week primigravida, arrives with her partner. She reports contractions "on and off all day," but now they're getting stronger. She is anxious and asking, "Is it time? Should I stay?" Nursing Intervention Strategy 1. Assessment: After obtaining vital signs and a focused history, perform a sterile vaginal exam (if indicated and per protocol). Your key objective finding is cervical dilation of 4 cm with 80% effacement, vertex at -1 station. 2. Nursing Diagnosis/Planning: Based on active labor diagnosis, the plan is to admit the client, initiate continuous electronic fetal monitoring (EFM), establish IV access, and provide labor support. 3. Implementation: * Communication: "Maria, your cervix has opened to about 4 centimeters, which means you are officially in active labor. We're going to admit you now and get you settled in a delivery room." * Actions: Admit to L&D room. Apply external fetal monitor. Start a saline lock or IV line. Review birth plan and discuss pain management options (e.g., epidural, IV analgesics). 4. Evaluation: Continuously monitor contraction pattern and FHR for reassuring signs. Reassess cervical dilation every 1-2 hours to evaluate progress. Patient Safety and Precautions * Contraindications: Do not allow a client with ruptured membranes and an unengaged fetal presenting part to ambulate widely, due to risk of umbilical cord prolapse. * Key Monitoring: Any deviation from expected progress (e.g., dilation Practice Questions 3,332 문제 · 로그인 없이 바로 볼 수 있어요 마이메르시로 국가고시 완벽 대비 기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요. 무료로 시작하기 App Store Google Play 학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.