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 B
Explanation
Choice A rationale
Hypertension is not a common side effect of epidural blocks; instead, hypotension is more likely due to vasodilation. Monitoring for hypertension is not the most important intervention.
Choice B rationale
Bradycardia is a potential side effect of epidural blocks due to sympathetic blockade. Monitoring the maternal pulse for bradycardia ensures timely intervention if this side effect occurs.
Choice C rationale
Epidural blocks do not typically cause fetal tachycardia. Monitoring the fetus for tachycardia is not the primary nursing intervention following epidural administration.
Choice D rationale
Limiting parenteral fluids is not advised after an epidural block as fluids are essential to counteract potential hypotension. Fluid management is crucial to maintain maternal and fetal hemodynamics.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Calling for help and notifying the care provider ensures that expert medical assistance is available promptly for any emergency interventions required.
Choice B rationale
Getting help and preparing the operating room ensures readiness for an immediate cesarean section if fetal distress persists and the situation does not improve rapidly.
Choice C rationale
Starting Pitocin is inappropriate during fetal distress as it may further stress the fetus by increasing contraction frequency and intensity, potentially worsening the situation.
Choice D rationale
Inserting a Foley catheter does not address the immediate concern of fetal distress and would not provide immediate benefit in improving fetal heart rate.
Choice E rationale
Repeating uterine resuscitation measures (e.g., repositioning, oxygen, IV fluids) is essential, but if they are ineffective, additional interventions, such as preparing for possible surgical delivery, are needed.
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