A client arrives in labor and delivery, and the L&D primary nurse gets a report from the L&D triage nurse.
How does the primary nurse interpret the following information on the client's labor: 2 cm, 60%, and -2 station?
2 cm dilated, 60% effaced, 2 cm below the ischial spines.
2 cm dilated, 60% effaced, 2 cm above the ischial spines.
2 cm effaced, 60% dilated, 2 cm below the ischial spines.
2 cm effaced, 60% dilated, 2 cm above the ischial spines.
The Correct Answer is B
Choice A rationale
2 cm dilated, 60% effaced, 2 cm below the ischial spines is incorrect because the -2 station means the presenting part is above the ischial spines, not below.
Choice B rationale
2 cm dilated, 60% effaced, 2 cm above the ischial spines correctly interprets the given data: cervical dilation, effacement, and station relative to the ischial spines.
Choice C rationale
2 cm effaced, 60% dilated, 2 cm below the ischial spines is incorrect because it reverses effacement and dilation figures and incorrectly places the station.
Choice D rationale
2 cm effaced, 60% dilated, 2 cm above the ischial spines is incorrect due to reversed effacement and dilation figures, though the station is correctly above the ischial spines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
- Blood pressure 160/105 mm Hg: This is abnormal as it is significantly elevated, which is a key indicator of preeclampsia.
- Reflexes 3+: This is abnormal and indicates hyperreflexia, often seen in preeclampsia.
- Platelet count 140,000/mm³: This is abnormal since it is on the lower end, suggesting mild thrombocytopenia, common in preeclampsia.
- Temperature 37.2°C: This is normal for a pregnant individual.
- Oxygen saturation 97%: This is normal, indicating adequate oxygenation.
Correct Answer is B
Explanation
Choice A rationale
2 cm dilated, 60% effaced, 2 cm below the ischial spines is incorrect because the -2 station means the presenting part is above the ischial spines, not below.
Choice B rationale
2 cm dilated, 60% effaced, 2 cm above the ischial spines correctly interprets the given data: cervical dilation, effacement, and station relative to the ischial spines.
Choice C rationale
2 cm effaced, 60% dilated, 2 cm below the ischial spines is incorrect because it reverses effacement and dilation figures and incorrectly places the station.
Choice D rationale
2 cm effaced, 60% dilated, 2 cm above the ischial spines is incorrect due to reversed effacement and dilation figures, though the station is correctly above the ischial spines.
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