The nurse has received a report regarding her patient in labor.
The woman’s last vaginal examination was recorded as 3 cm, 30%, and -2. The nurse’s interpretation of this assessment is that:
The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines.
The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines.
The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below the ischial spines.
The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines.
The Correct Answer is B
Choice A rationale
The cervix is measured in dilation, not effacement, in centimeters. Effacement is expressed in percentage, indicating the thinning of the cervix.
Choice B rationale
The cervix is 3 cm dilated, 30% effaced, and the presenting part is 2 cm above the ischial spines. This assessment provides a clear status of labor progress.
Choice C rationale
The presenting part being below the ischial spines would be recorded with a positive station, indicating descent into the pelvis, unlike this assessment.
Choice D rationale
The cervix is assessed for dilation in centimeters and effacement in percentage, with station indicating the relationship to the ischial spines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Starting Pitocin at a low dose minimizes the risk of uterine hyperstimulation, which can cause fetal distress. Gradually increasing the dose allows careful monitoring of the mother’s and fetus’s responses for optimal contraction rate.
Choice B rationale
Administering Pitocin without starting at a low dose increases the risk of uterine tachysystole, leading to potential complications like uterine rupture or placental abruption. A gradual increase ensures safer labor progression.
Correct Answer is B
Explanation
Choice A rationale
Although the placenta acts as a partial barrier, it does not keep out all harmful substances, allowing some to cross and affect fetal development.
Choice B rationale
One of the placenta's early functions is producing hormones like human chorionic gonadotropin (hCG), estrogen, and progesterone, making it act as an endocrine gland.
Choice C rationale
The placenta does not thin out; it remains robust and increases in thickness to support the growing fetus and facilitate nutrient and gas exchange.
Choice D rationale
While optimal blood circulation through the placenta is crucial, this statement lacks detail on the specific structural and functional aspects of the placenta.
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