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.
Core Nursing ExplanationKey Concept Analysis: This question assesses your ability to identify the normal characteristics of Active labor, which is part of the First stage of labor. The first stage is divided into three phases: Latent, Active, and Transition. The key to answering this question is recognizing the contraction pattern, cervical dilation, and effacement that define the active phase.
Answer Rationale: Key Point! For a primigravida at 38 weeks, normal progression into active labor is characterized by regular, frequent, and strong contractions along with significant cervical change. Option ③ describes contractions every 3-4 minutes, lasting 45-60 seconds, with moderate to strong intensity. This pattern is the classic hallmark of the active phase, where cervical dilation typically progresses from about 6 cm to 10 cm. This indicates effective labor and normal progression.
Distractor Analysis:
Watch out for confusion! Option ① describes contractions every 8-10 minutes lasting 30 seconds. This pattern is characteristic of Early or Latent labor, not active labor. The contractions are too infrequent, too short, and of mild intensity.
Watch out for confusion! Option ② describes a cervix that is 2 cm dilated and 25% effaced. This is also a finding of Latent labor. While it's a normal finding for that early phase, it does not indicate progression into the active phase of the first stage.
Watch out for confusion! Option ④ presents a Fetal Heart Rate (FHR) baseline of 110 bpm (the lower limit of normal is 110-160 bpm) with Late decelerations. Late decelerations are a non-reassuring fetal status indicating possible uteroplacental insufficiency. This is an abnormal finding requiring intervention, not an indicator of normal labor progress.
Related Concepts: Understanding the stages and phases of labor is fundamental. The first stage ends with full cervical dilation (10 cm). The second stage is from full dilation to delivery of the baby. The third stage is from delivery of the baby to delivery of the placenta. Nursing assessments must continuously monitor both maternal progress (contractions, cervix) and fetal well-being (FHR patterns).
Concept Summary
Labor Phase (First Stage)
Cervical Dilation
Contraction Pattern
Duration (Primigravida)
Latent (Early) Phase
0 to 6 cm
Irregular to regular, mild, 5-30 min apart, 30-45 sec long
Up to 20 hours
Active Phase
6 to 10 cm
Regular, moderate to strong, 3-5 min apart, 45-60 sec long
Up to 8 hours
Transition Phase
8 to 10 cm
Strong to very strong, 2-3 min apart, 60-90 sec long
30 min - 2 hours
Side-by-Side Comparison!
Assessment Finding
Indicates...
Nursing Action
Contractions q3-4min, 60 sec, strong
Normal Active Labor Progress
Continue monitoring, provide support and comfort measures.
FHR with Late Decelerations
Non-reassuring Fetal Status (Abnormal)
Immediate action: Change maternal position (left lateral), administer O2, stop oxytocin if running, notify provider.
Cervix 2 cm / 25% effaced
Latent Labor (Early Phase)
May encourage ambulation, hydration, and rest at home if appropriate (depending on protocol).
Anatomy, Physiology & Pharmacology Points
• Physiology: Effective labor contractions involve a fundal dominance pattern—starting at the top (fundus) of the uterus and spreading downward—which is most efficient for cervical dilation and fetal descent.
• Pharmacology: Oxytocin (Pitocin) is a drug used to augment labor. It must be titrated carefully to achieve a contraction pattern similar to normal active labor (q2-3 min, lasting <90 sec) while continuously monitoring for uterine hyperstimulation and non-reassuring FHR patterns.
Memory Tips
• Active Labor Contractions: Remember the "Rule of 3-5-60": Contractions every 3-5 minutes, lasting about 60 seconds.
• Stages of Labor: Mnemonic "1st = Dilation, 2nd = Delivery, 3rd = Detachment (of placenta)".
High-Frequency NCLEX Topics
This is a Core topic. The NCLEX frequently tests:
1. Differentiating between phases of the first stage of labor based on contraction patterns and cervical findings.
2. Identifying normal vs. abnormal FHR patterns (e.g., early vs. variable vs. late decelerations).
3. Knowing priority nursing interventions for non-reassuring fetal status.
Watch Out for Question Variations!
• Instead of asking for a sign of normal progress, the question might ask: "Which finding requires immediate intervention by the nurse?" The answer would then shift to the option with late decelerations (Option ④).
• The question could be framed around a multiparous client, where labor progresses much faster. Normal active labor for a multipara might involve contractions every 2-3 minutes.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in Labor & Delivery. Maria, a 25-year-old primigravida at 39 weeks, is admitted. She reports contractions that started 6 hours ago and are now "very strong and coming fast." She is anxious and having difficulty coping with the pain.
Nursing Intervention Strategy:
1AssessmentPerform a focused assessment. Time her contractions: they are every 3 minutes, lasting 55 seconds, palpated as strong. Check the electronic fetal monitor: FHR baseline 140 bpm with accelerations, no decelerations. A vaginal exam by the provider reveals cervix is 7 cm dilated, 90% effaced, and the fetus is at -1 station. Key Point! This confirms she is in the Active phase of labor.
2Nursing Diagnosis & PlanningAcute pain related to uterine contractions and tissue dilation. The plan is to provide non-pharmacological and pharmacological pain relief and continuous support.
3Implementation• Provide continuous emotional support and encouragement.
• Assist with breathing techniques (e.g., patterned-paced breathing).
• Offer position changes (e.g., upright, side-lying, hands-and-knees) to promote comfort and fetal descent.
• Administer prescribed analgesia (e.g., IV opioids) or prepare for epidural anesthesia if requested.
• Continue continuous electronic fetal monitoring (EFM) or intermittent auscultation per protocol.
4EvaluationReassess pain level, contraction pattern, and FHR every 15-30 minutes. Evaluate cervical progress in 1-2 hours to ensure labor is advancing.
Patient Safety and Precautions:
• Never leave a patient in active labor unattended for prolonged periods.
• Be vigilant for signs of non-reassuring fetal status (e.g., late or variable decelerations, bradycardia, minimal variability).
• Monitor for signs of maternal exhaustion or dehydration.
Nursing Procedure & Medication FlowProcedure: Assisting with Epidural Anesthesia
1Pre-procedureEnsure informed consent is obtained. Establish a large-bore IV line and administer a preload of IV fluids (e.g., 500-1000 mL Lactated Ringer's) to prevent hypotension.
2During procedureAssist the anesthesiologist by positioning the patient (sitting or lateral) and providing support. Monitor maternal BP every 2-5 minutes after the test dose and initial bolus.
3Post-procedureMonitor for complications: Maternal hypotension (treat with position change, IV fluids, and possibly ephedrine), Urinary retention (may require catheterization), and Pruritus (itching, treat with diphenhydramine if ordered).
A Word from Your Senior Nurse
"Labor is a dynamic process, and your role as the nurse is to be the calm, knowledgeable guide. Recognizing the shift from latent to active labor is crucial because it changes everything—the patient's needs, the frequency of monitoring, and the urgency of pain management options. On the NCLEX, they love to test if you can distinguish 'normal progress' from 'needs intervention.' In real life, that skill is how you keep both mom and baby safe. Always tie your knowledge back to the two patients you're caring for: the birthing person and the fetus."
Active Labor — The phase of the first stage of labor from approximately 6 cm to full cervical dilation (10 cm), characterized by regular, strong contractions every 3-5 minutes lasting 45-60 seconds.
Cervical Dilation — The opening of the cervical os, measured in centimeters from 0 (closed) to 10 (fully dilated), which is the primary indicator of progress during the first stage of labor.
Late Decelerations — A pattern of the fetal heart rate where the nadir (lowest point) of the deceleration occurs after the peak of the uterine contraction. It suggests uteroplacental insufficiency and is a non-reassuring sign.
Primigravida — A woman who is pregnant for the first time. Labor typically progresses more slowly for a primigravida compared to a multigravida.
Effacement — The thinning and shortening of the cervix, expressed as a percentage from 0% (thick) to 100% (completely thin). Effacement often occurs before significant dilation in first-time mothers.