A nurse is examining a client who is in active labor and observes that the presenting part is in the left occiput posterior position.
What is the clinical interpretation of this finding?
The posterior fontanel is palpable.
The lowermost portion of the fetus is at the level of the ischial spines.
The largest fetal diameter has passed through the pelvic outlet.
The fetal head is in the left occiput posterior position.
The Correct Answer is D
Choice A rationale
The palpability of the posterior fontanel is not related to the position of the fetus.
Choice B rationale
The level of the ischial spines refers to the station of the fetus, not its position.
Choice C rationale
The passage of the largest fetal diameter through the pelvic outlet is a stage of labor, not a fetal position.
Choice D rationale
This is the correct answer. The left occiput posterior position refers to the position of the fetal head.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Correct Answer is A
Explanation
Choice A rationale
Cervical dilation is a positive sign of labor. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a definitive sign that labor is occurring.
Choice B rationale
Amniotic fluid in the vaginal vault could indicate rupture of membranes, but it does not confirm labor. Labor may or may not be present when the membranes rupture.
Choice C rationale
Pain above the umbilicus is not a typical sign of labor. Labor pain is usually felt in the lower back and lower abdomen.
Choice D rationale
Brownish vaginal discharge could be a sign of “bloody show,” which can occur as labor approaches. However, it does not confirm that labor is occurring.
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