A nurse is caring for a primigravida at 40 weeks gestation in active labor. The most recent vaginal exam reveals the cervix is 6 cm dilated, 100% effaced, and the fetal station is 0. Which of the following interpretations and nursing actions are most appropriate based on this assessment? Select all that apply.
The fetus is in engagement, and further descent is expected as labor progresses.
Immediate provider notification is not required, but continued monitoring is necessary for signs of labor progression.
Although the patient is not yet in transition, contractions are likely becoming more intense and closer together.
Fetal station indicates the presenting part is at the level of the ischial spines.
Complete effacement with 6 cm dilation indicates favorable cervical change and progression.
The cervix is fully dilated and the patient will begin pushing soon.
Correct Answer : A,B,C,D,E
A. The fetus is in engagement, and further descent is expected as labor progresses: A fetal station of 0 means the presenting part is at the level of the ischial spines, confirming engagement. Continued descent is expected as contractions increase in strength and frequency.
B. Immediate provider notification is not required, but continued monitoring is necessary for signs of labor progression: The findings reflect normal active labor progress. The nurse should continue monitoring maternal and fetal status, documenting changes, and supporting the client through ongoing cervical dilation and fetal descent.
C. Although the patient is not yet in transition, contractions are likely becoming more intense and closer together: At 6 cm dilation, the client is in the active phase of labor, where contractions typically occur every 3–5 minutes and increase in intensity as the cervix continues to dilate toward the transition phase.
D. Fetal station indicates the presenting part is at the level of the ischial spines: A station of 0 identifies the presenting fetal part as aligned with the ischial spines, representing the narrowest part of the maternal pelvis and confirming engagement.
E. Complete effacement with 6 cm dilation indicates favorable cervical change and progression: Full effacement and progressive dilation are reassuring signs that the cervix is responding effectively to uterine contractions and that labor is advancing normally.
F. The cervix is fully dilated and the patient will begin pushing soon: Full dilation is 10 cm, not 6 cm. The client is still in the active phase and should not begin pushing until complete dilation is achieved to prevent cervical trauma or fatigue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Voluntary bearing down efforts: The strength, timing, and coordination of the mother's pushing efforts significantly affect fetal descent and the progress of the second stage of labor. Ineffective bearing down can delay birth, while effective efforts promote smoother fetal expulsion.
B. The shape of the woman's bony pelvis: Pelvic shape and dimensions determine how easily the fetal head can pass through the birth canal. A gynecoid pelvis is most favorable, whereas android or platypelloid types can impede progress and increase labor complications.
C. Antibiotic administration for a GBS + patient: While antibiotics are essential for preventing neonatal infection, they do not influence the physical mechanics or progression of labor. Their purpose is prophylactic rather than to affect the labor process itself.
D. Size of the fetal head: A large fetal head relative to the maternal pelvis can lead to cephalopelvic disproportion, slowing or arresting labor progress. Optimal fit between fetal head size and pelvic dimensions promotes efficient descent and delivery.
E. Presentation of the fetus: The way the fetus enters the pelvis—whether cephalic, breech, or face presentation—directly affects labor progression. Cephalic presentation, especially occiput anterior, allows for smoother navigation through the pelvis.
Correct Answer is A
Explanation
A. "The shiny Schultz side is the fetal side, smooth and shiny, delivered first in most cases.": The Schultz side of the placenta is the fetal surface, covered by the amnion, giving it a smooth, shiny appearance. It is often delivered first and represents the side facing the fetus in utero.
B. "The dirty Duncan side is the fetal side, smooth and shiny, that faces the baby.": The dirty Duncan side is not the fetal surface; it is the maternal side. It appears rough and reddish due to the presence of cotyledons where the placenta was attached to the uterine wall.
C. "The dirty Duncan side is smooth and shiny and indicates incomplete placental separation.": The Duncan side is rough and irregular, not smooth. Its appearance does not indicate incomplete separation but rather represents the natural maternal attachment surface of the placenta.
D. "The shiny Schultz side is the maternal side that attaches to the uterine wall.": The Schultz side is the fetal side, not the maternal attachment surface. The maternal side (Duncan) attaches to the uterus, while the Schultz side faces the fetus and is lined with amniotic membrane.
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