A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

The lowermost portion of the fetus is at the level of the ischial spines.

The largest fetal diameter has passed through the pelvic outlet.

The posterior fontanel is palpable.

The fetal head is in the left occiput posterior positions

Answer and Explanation

The Correct Answer is A

A. The lowermost portion of the fetus is at the level of the ischial spines.

A. The lowermost portion of the fetus being at the level of the ischial spines is the correct interpretation of 0 station. In the station system, when the presenting part is at the level of the ischial spines, it is referred to as 0 station.

B. The largest fetal diameter passing through the pelvic outlet is generally represented by the complete passage of the fetus through the birth canal. This is more indicative of full cervical dilation (10 cm) rather than a specific station.

C. The posterior fontanel being palpable is not directly related to the concept of station. Fontanel palpation is more associated with determining fetal head position.

D. The fetal head being in the left occiput posterior position is related to fetal position, not station. The station describes the descent of the presenting part in relation to the ischial spines.

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Correct Answer is B

Explanation

Choice A Reason:

Active is incorrect. The active phase of labor typically begins when the cervix is around 4 to 6 centimeters dilated. Given that the client's cervix is already dilated to 9 cm, she has progressed beyond the active phase.

Choice B Reason:

Transition is correct. The transition phase is the final part of the first stage of labor and occurs when the cervix is dilated from 8 to 10 centimeters. In this phase, contractions are typically strong, occurring every 2 to 3 minutes, and lasting 80 to 90 seconds. The sensation of increasing rectal pressure is common during the transition phase as the baby's head descends further into the birth canal. The advanced cervical dilation to 9 cm also indicates that the client is in the transition phase, preparing for the second stage of labor.

Choice C Reason:

Latent is incorrect. The latent phase is the early part of the first stage of labor, characterized by cervical dilation from 0 to 3 or 4 centimeters. The client's cervix is already dilated to 9 cm, indicating that she has progressed well beyond the latent phase.

Choice D Reason:

Descent is incorrect. The descent phase is generally associated with the second stage of labor, during which the baby moves through the birth canal. The information provided primarily relates to the first stage of labor, specifically the transition phase, as indicated by the cervical dilation of 9 cm.

A. A distended bladder will be traumatized by frequent pelvic exams B. A distended bladder reduces pelvic space needed for birth. C. A full bladder increases the risk for fetal trauma trauma D. A full bladder increases the risk for bladder infections

Correct Answer is B

Explanation

The correct answer is B. A distended bladder reduces pelvic space needed for birth.

A. A distended bladder itself is not typically traumatized by pelvic exams. However, a full bladder can impede the progress of labor and may affect the accuracy of pelvic exams.

B. This statement is accurate. A distended bladder can reduce the available pelvic space needed for the descent of the baby during labor. An empty bladder allows the fetal head to engage more easily in the pelvis.

C. A full bladder is not directly associated with an increased risk for fetal trauma. The primary concern is the impact on pelvic space and the progress of labor.

D. While a full bladder can contribute to urinary tract infections, it is not the primary reason for encouraging the client to avoid a distended bladder during labor.

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A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

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Correct Answer is B

Explanation

A nurse is caring for a client who was in the first stage of labor and is encouraging the client to void every two hours. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

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