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 posterior fontanel is palpable.

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

The fetal head is in the left occiput posterior position.

The largest fetal diameter has passed through the pelvic outlet.

Answer and Explanation

The Correct Answer is B

A) The posterior fontanel is palpable:
This statement is not directly related to station. The fontanelles are soft spots on the fetal skull used to assess fetal head position, but they are not specifically related to station.

B) The lowermost portion of the fetus is at the level of the ischial spines:
In obstetrics, station refers to the relationship between the presenting part of the fetus and the maternal ischial spines. When the presenting part is at 0 station, it means that the lowest part of the fetus (usually the head) is at the level of the maternal ischial spines. This is a significant landmark indicating the progress of labor. As labor progresses, the fetus descends further into the pelvis, with stations progressing from -3 to +3.

C) The fetal head is in the left occiput posterior position:
The station does not provide information about the fetal head position. Left occiput posterior position refers to the position of the fetal head in relation to the maternal pelvis, which is determined separately through pelvic examinations.

D) The largest fetal diameter has passed through the pelvic outlet:
While 0 station indicates engagement of the fetal head in the pelvis, it does not necessarily mean that the largest fetal diameter has passed through the pelvic outlet. Labor continues until the entire fetus is delivered through the birth canal, which occurs as labor progresses through the different stages.

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Correct Answer is A

Explanation

A) Have the client ambulate:
Encouraging the client to ambulate is important for preventing thromboembolic complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Early ambulation promotes venous return, reduces stasis, and decreases the risk of blood clots forming in the lower extremities. However, the nurse should ensure the client's safety and provide assistance as needed.

B) Apply warm, moist heat to the client's lower extremities:
While warm, moist heat can provide comfort, it is not the priority intervention for a client with a history of thromboembolic disease. In fact, heat application could potentially increase blood flow to the lower extremities, which may exacerbate the risk of thrombosis in this client population.

C) Place pillows under the client's knees when resting in bed:
Placing pillows under the client's knees can help alleviate pressure on the lower back and enhance comfort, but it does not directly address the prevention of thromboembolic complications in a client with a history of thromboembolic disease.

D) Massage the client's posterior lower legs:
Massaging the client's posterior lower legs is contraindicated in individuals with a history of thromboembolic disease, as it can potentially dislodge blood clots and lead to embolism. This intervention could increase the risk of thromboembolic events rather than prevent them.

A. Encourage the client to empty her bladder every 2 hr. B. Maintain the client in the lithotomy position. C. Perform vaginal examinations frequently. D. Remind the client to bear down with each contraction.

Correct Answer is A

Explanation

A) Encourage the client to empty her bladder every 2 hr: After amniotomy, it's essential for the client to empty her bladder regularly to prevent bladder distention, which can impede the progress of labor and increase discomfort. A distended bladder can also obstruct the descent of the fetus, leading to prolonged labor and increased risk of bladder injury.

B) Maintain the client in the lithotomy position: The lithotomy position is typically used during the second stage of labor, not the active phase of the first stage. During the active phase, the client is usually allowed to move freely or assume positions that promote comfort and labor progression.

C) Perform vaginal examinations frequently: While vaginal examinations may be necessary to assess cervical dilation and fetal descent, performing them frequently increases the risk of infection and discomfort. Vaginal examinations should be performed judiciously and only when necessary to avoid introducing microorganisms into the birth canal.

D) Remind the client to bear down with each contraction: Bearing down (pushing) is typically done during the second stage of labor when the cervix is fully dilated. During the active phase of the first stage, the focus is on cervical dilation and effacement, and the client is encouraged to use coping strategies such as relaxation, breathing techniques, and position changes to manage contractions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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