The nurse is assessing a patient who thinks she is in labor. Which findings would positively confirm the woman is in labor? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply
1. She is contracting every 5 minutes for 60 seconds.
2. Her cervix has dilated from 2 to 4 centimeters.
3. Her membranes have ruptured.
4. The fetal head is engaged.
5. The contractions are starting in the back and radiating around to the front of the abdomen with uterine relaxation between contractions.
2,5
Rationale 1: Women can have contractions without being in true labor.
Rationale 2: Once the cervix starts to dilate, the patient is in true labor.
Rationale 3: Membranes can rupture before true labor begins.
Rationale 4: Engagement can take place before true labor begins.
Rationale 5: It is usually a sign of true labor when contraction pains begin in the back and radiate to the front.
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