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 True
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 D
Explanation
Choice A rationale
Placental insufficiency can cause late decelerations in fetal heart rate due to decreased blood flow, but it typically shows a gradual decrease rather than the abrupt patterns seen here.
Choice B rationale
Abruption usually presents with painful vaginal bleeding and a tender uterus, rather than specific changes in fetal heart rate patterns like those described in the question.
Choice C rationale
Head compression results in early decelerations, which appear as a mirror image of contractions, but these are not sudden drops in heart rate typically seen in cord compression.
Choice D rationale
Cord compression leads to variable decelerations characterized by sudden drops in fetal heart rate, caused by temporary reduction in oxygen flow to the fetus. This matches the tracing pattern described.
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