A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

The fetal head is in the left occiput posterior position.

The largest fetal diameter has passed through the pelvic outlet.

The posterior fontanel is palpable.

The lowermost portion of the fetus is at the level of the ischial spines.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.

Choice B rationale:

The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.

Choice C rationale:

The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.

Choice D rationale:

This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.

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Correct Answer is B

Explanation

Choice A reason:

Nevus flammeus, also known as a port-wine stain, is a flat, pink, red, or purple mark on the skin present at birth. It is a congenital vascular malformation and does not involve swelling that crosses suture lines.

Choice B reason:

Caput succedaneum is the correct diagnosis for swelling that crosses suture lines on a newborn's head, typically associated with a prolonged or difficult vaginal delivery, especially with the use of vacuum extraction.

Choice C reason:

Cephalohematoma is a collection of blood under the periosteum of the cranial bones that does not cross suture lines. It appears soon after birth and is usually caused by birth trauma.

Choice D reason:

Erythema toxicum is a common rash in newborns, presenting as red patches with small white or yellow pustules. It does not cause swelling over the head that crosses suture lines.

A. Contraction frequency every 3 minutes. B. Contraction duration of 100 seconds. C. Fetal heart rate with moderate variability. D. Fetal heart rate of 118/min.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should discontinue the oxytocin infusion if the client's contraction frequency is every 3 minutes. Frequent contractions may lead to uterine hyperstimulation, which can reduce fetal blood flow and oxygenation, potentially causing fetal distress. Normal contraction frequency during labor is typically every 2 to 5 minutes.

Choice B rationale:

Contraction duration of 100 seconds is not an indication to discontinue the oxytocin infusion. The duration of contractions can vary during labor, and 100 seconds is within the normal range of contraction duration, which is usually 45 to 90 seconds.

Choice C rationale:

Fetal heart rate with moderate variability is not an indication to discontinue the oxytocin infusion. Moderate variability in fetal heart rate is a reassuring sign, indicating a healthy fetal response to labor. It shows that the fetus is tolerating the contractions well and is not experiencing fetal distress.

Choice D rationale:

A fetal heart rate of 118/min is not an indication to discontinue the oxytocin infusion. The normal fetal heart rate range is typically between 110 to 160 beats per minute, and a heart rate of 118/min falls within this normal range. However, if the fetal heart rate deviates significantly from the normal range or shows signs of distress, further assessment and intervention are required.

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A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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