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 D
Explanation
Choice A rationale
Valsalva maneuver involves forced expiration against a closed airway, increasing intrathoracic pressure and commonly used to expel the fetus during the second stage of labor.
Choice B rationale
Ferguson’s reflex involves the release of oxytocin due to vaginal and cervical stretching, leading to stronger contractions during the second stage of labor.
Choice C rationale
Lightening refers to the descent of the fetus into the pelvis before labor begins, reducing pressure on the diaphragm and making breathing easier.
Choice D rationale
Molding is the slight overlapping of cranial bones, allowing the fetal head to change shape and fit through the birth canal during labor.
Correct Answer is A
Explanation
Choice A rationale
The tocodynamometer detects both the frequency and intensity of uterine contractions by measuring the pressure changes on the abdomen. It provides real-time data on contraction patterns during labor.
Choice B rationale
Repeating the frequency and intensity of contractions is redundant. The tocodynamometer accurately measures these parameters, providing essential information for managing labor progress.
Choice C rationale
While the tocodynamometer can infer uterine resting tone, it is not designed to measure hypertonus directly. Other methods, like intrauterine pressure catheters, offer more accurate assessments of uterine tone.
Choice D rationale
The tocodynamometer measures the duration of contractions, but it does not solely focus on this parameter. It captures comprehensive data, including frequency and intensity, for effective labor management.
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