A client arrives in labor and delivery, and the L&D primary nurse gets a report from the L&D triage nurse.
How does the primary nurse interpret the following information on the client's labor: 2 cm, 60%, and -2 station?
2 cm dilated, 60% effaced, 2 cm below the ischial spines.
2 cm dilated, 60% effaced, 2 cm above the ischial spines.
2 cm effaced, 60% dilated, 2 cm below the ischial spines.
2 cm effaced, 60% dilated, 2 cm above the ischial spines.
The Correct Answer is B
Choice A rationale
2 cm dilated, 60% effaced, 2 cm below the ischial spines is incorrect because the -2 station means the presenting part is above the ischial spines, not below.
Choice B rationale
2 cm dilated, 60% effaced, 2 cm above the ischial spines correctly interprets the given data: cervical dilation, effacement, and station relative to the ischial spines.
Choice C rationale
2 cm effaced, 60% dilated, 2 cm below the ischial spines is incorrect because it reverses effacement and dilation figures and incorrectly places the station.
Choice D rationale
2 cm effaced, 60% dilated, 2 cm above the ischial spines is incorrect due to reversed effacement and dilation figures, though the station is correctly above the ischial spines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Reducing carbohydrate intake is part of dietary management in gestational diabetes.
Choice B rationale
Women with gestational diabetes have an increased risk of developing type 2 diabetes later in life.
Choice C rationale
Increasing exercise is beneficial for managing blood sugar levels in gestational diabetes.
Choice D rationale
Glyburide is not typically the first-line treatment for gestational diabetes; insulin is often recommended for better control.
Correct Answer is D
Explanation
Choice A rationale
Allowing the client to ambulate in the hallway to initiate labor is not the first appropriate action because it does not address the immediate need to monitor the client's temperature. Ambulation can be considered after ensuring there are no signs of infection or other complications.
Choice B rationale
Encouraging oral fluids and administering an antipyretic medication is not the initial priority. While hydration is important, the primary focus should be on monitoring for signs of infection, which can be indicated by changes in temperature.
Choice C rationale
Administering glucocorticoids intramuscularly is typically for promoting fetal lung maturity in cases of preterm labor, not for term pregnancies at 38 weeks. It does not address the immediate need to monitor maternal temperature after membrane rupture.
Choice D rationale
Checking the client's temperature every 2 hours is crucial to monitor for signs of infection, such as chorioamnionitis, which can occur after membrane rupture. Early detection of fever can prevent complications for both mother and baby.
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