A first-time mother presents for a labor check.
She is informed that her vaginal exam shows dilated (3 cm), effaced (100%), and fetal station (-2). What explanation is the most appropriate response by the nurse?

Your cervix is open a little and the baby is very low.

Your cervix is all thinned out and the baby is very low.

Your cervix is open a little, but the baby is still high in the pelvis.

Your cervix is open a little, but still needs to thin out.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While a dilation of 3 cm indicates some cervical opening, stating the baby is "very low" with a station of -2 is inaccurate. A negative station indicates the presenting part is above the ischial spines, not low in the pelvis.

Choice B rationale

A cervical effacement of 100% means the cervix has fully thinned out. A fetal station of -2 indicates the presenting part of the fetus is 2 cm above the ischial spines. Therefore, the cervix is completely thinned, and the baby's head is relatively high in the pelvis.

Choice C rationale

Although the cervix is dilated to 3 cm, indicating some opening, the fetal station of -2 signifies that the baby is still high in the pelvis, not low. This statement correctly identifies the dilation but inaccurately describes the fetal descent.

Choice D rationale

A cervical dilation of 3 cm indicates the cervix is open to some extent. However, the 100% effacement indicates that the cervix is already completely thinned out, so the statement that it "still needs to thin out" is incorrect.

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Correct Answer is D

Explanation

Choice A rationale

A 34-week client with no fetal heartbeat requires specialized care and emotional support due to fetal demise. This situation involves complex emotional and physical considerations beyond the scope of a new nurse's experience.

Choice B rationale

A 32-week patient with preeclampsia receiving magnesium sulfate is a high-risk pregnancy requiring close monitoring for signs of magnesium toxicity (e.g., respiratory depression, decreased reflexes) and worsening preeclampsia. This level of care is not appropriate for a new OB nurse.

Choice C rationale

A 38-week client with complete previa, where the placenta completely covers the cervical os, is at high risk for hemorrhage during labor and delivery. This requires experienced obstetric nursing care and preparation for potential cesarean section.

Choice D rationale

A 9-week client with hyperemesis gravidarum receiving IV therapy for dehydration and electrolyte imbalance requires assessment of hydration status, electrolyte levels, and management of nausea and vomiting. While requiring nursing care, this situation is generally more stable and less complex than the other options, making it a more appropriate assignment for a new nurse under the supervision of an experienced charge nurse.

B. Bright red vaginal bleeding. C. Closed cervix upon examination. M. Mild to moderate lower abdominal cramping.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale

Severe cramping and pelvic pain are more indicative of an inevitable or incomplete abortion, where the pregnancy is no longer viable and the body is actively trying to expel the uterine contents. In a threatened abortion, the symptoms are typically milder.

Choice B rationale

A closed cervix upon examination is a key finding in a threatened abortion. It indicates that the uterus is not yet dilating or effacing, suggesting that the pregnancy might still be maintained. Cervical dilation signifies progression towards abortion.

Choice C rationale

Mild to moderate lower abdominal cramping is a common symptom of a threatened abortion. These cramps result from uterine irritability and contractions as the body reacts to potential pregnancy loss. The intensity is less severe than in later stages of abortion.

Choice D rationale

Passage of fetal tissue is a definitive sign of an incomplete or complete abortion, meaning the pregnancy has already been lost and the products of conception are being expelled. This would not be expected in a threatened abortion.

Choice E rationale

Bright red vaginal bleeding is a common symptom of a threatened abortion, indicating disruption at the decidual-trophoblastic interface. The bleeding can range from spotting to light bleeding and suggests a potential threat to the pregnancy.

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A first-time mother presents for a labor check.She is informed that her vaginal exam shows dilated (3 cm), effaced (100%), and fetal station (-2). What explanation is the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following gravid clients is most appropriate for a charge nurse to assign to a new nurse with no obstetric (OB) experience?

Correct Answer is D

Explanation

Correct Answer is ["B","C","E"]

Explanation

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For each medication below, click to select the appropriate nursing action. (Each category can have zero or more response options selected)

A first-time mother presents for a labor check.She is informed that her vaginal exam shows dilated (3 cm), effaced (100%), and fetal station (-2). What explanation is the most appropriate response by the nurse?

A first-time mother presents for a labor check.
She is informed that her vaginal exam shows dilated (3 cm), effaced (100%), and fetal station (-2). What explanation is the most appropriate response by the nurse?