The nurse has received a report regarding her patient in labor. The woman's last vaginal examination was recorded as 2 cm, 80%, and +2. The nurse's interpretation of this assessment is that:

Select one:

The cervix is dilated 2 cm, it is effaced 80%, and the presenting part is 2 inches below the ischial spines.

The cervix is 2 cm dilated, it is effaced 80%, and the presenting part is 2 cm above the ischial spines.

The cervix is dilated 2 cm, it is effaced 80%, and the presenting part is 2 cm below the ischial spines.

The cervix is effaced 2 cm, it is dilated 80%, and the presenting part is 2 cm above the ischial spines.

Answer and Explanation

The Correct Answer is C

a.   This is an incorrect interpretation of the assessment.
b.   This is an incorrect interpretation of the assessment.
c.   This is the correct interpretation of the assessment indicating that the labor is progressing well and the baby is descending into the pelvis.
d.   This is an incorrect interpretation of the assessment.

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Correct Answer is A

Explanation

a. An abnormal odor of the amniotic fluid, such as a foul or fishy smell, may indicate infection and is a concern with ruptured membranes and an elevated temperature.
b. This may be necessary if the client has an infection or other complications, but it is not the first action to take.
c. This is not an appropriate action when the client has an elevated temperature and ruptured membranes.
d. Glucocorticoids may be administered to promote fetal lung maturity in preterm labor, but they are not appropriate in this situation.

A. Maternal hypotension B. Pulmonary edema. C. Fetal bradycardia D. Fetal hypokalemia E. Fetal hypokalemia

Correct Answer is B

Explanation

a. Maternal hypotension is not a common side effect of terbutaline, which is a beta-adrenergic agonist that can cause tachycardia and hypertension.
b. Pulmonary edema is a serious complication of terbutaline therapy, which can cause fluid overload, dyspnea, chest pain, and crackles in the lungs. The nurse should monitor the woman's vital signs, oxygen saturation, urine output, and lung sounds, and report any signs of pulmonary edema to the physician immediately.
c. Fetal bradycardia is not related to terbutaline, which can cause fetal tachycardia.
d. Fetal hypokalemia is also not associated with terbutaline, which can cause maternal hypokalemia due to increased potassium uptake by the cells.

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The nurse has received a report regarding her patient in labor. The woman's last vaginal examination was recorded as 2 cm, 80%, and +2. The nurse's interpretation of this assessment is that: Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action?

Correct Answer is A

Explanation

The nurse is administering Terbutaline (Brethine) to a pregnant woman to stop preterm labor. Which finding indicates an adverse reaction and the Physician must be notified? Select one:

Correct Answer is B

Explanation

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Physiologic anemia often occurs during pregnancy as a result of

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Through vaginal examination, the nurse determines that the woman is 8 cm dilated, and the external fetal monitor shows uterine contractions every 3 minutes and a duration of 50 seconds. The nurse would report these findings as:

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A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

The nurse has received a report regarding her patient in labor. The woman's last vaginal examination was recorded as 2 cm, 80%, and +2. The nurse's interpretation of this assessment is that:

Select one: