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

The largest fetal diameter has passed through the pelvic outlet.

The posterior fontanel is palpable.

The fetal head is in the left occiput posterior positions

Answer and Explanation

The Correct Answer is A

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

A. The lowermost portion of the fetus being at the level of the ischial spines is the correct interpretation of 0 station. In the station system, when the presenting part is at the level of the ischial spines, it is referred to as 0 station.

B. The largest fetal diameter passing through the pelvic outlet is generally represented by the complete passage of the fetus through the birth canal. This is more indicative of full cervical dilation (10 cm) rather than a specific station.

C. The posterior fontanel being palpable is not directly related to the concept of station. Fontanel palpation is more associated with determining fetal head position.

D. The fetal head being in the left occiput posterior position is related to fetal position, not station. The station describes the descent of the presenting part in relation to the ischial spines.

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Correct Answer is B

Explanation

A. Contractions that last 45 seconds each with a 3-minute rest between contractions are less common. Typically, contractions last around 60 seconds during active labor.

B. Contractions that last for 60 seconds each with a 3-min rest between contractions is the expected pattern.

During active labor, contractions are commonly around 60 seconds in duration, and they occur approximately every 4-5 minutes.

C. Contractions that last for 60 seconds each with a 4-min rest between contractions are not consistent with the usual pattern of contractions in active labor. A 4-minute rest between contractions would be an extended interval.

D. A contraction that lasts for 4 minutes followed by a period of relaxation is not typical and may indicate a problem. Normal contractions usually last around 60 seconds or less.

A. Monitor the fetal heart rate (FHR) every hour B. Insert an indwelling urinary catheter. C. Keep four side rails up while the client is in bed D. Check the cervix prior to analgesic administration

Correct Answer is A

Explanation

The correct answer is A. Monitor the fetal heart rate (FHR) every hour.

A. Monitoring the fetal heart rate every hour is a crucial aspect of the plan of care during active labor. Continuous fetal monitoring helps assess the well-being of the baby and ensures timely identification of any signs of fetal distress.

B. Inserting an indwelling urinary catheter is not a routine intervention during active labor. The bladder can be monitored using other non-invasive methods, and catheterization is generally reserved for specific indications.

C. Keeping four side rails up while the client is in bed is not recommended. It may limit the client's mobility and is not a standard practice during labor. Ensuring the safety of the client and promoting mobility is important.

D. Checking the cervix prior to analgesic administration may be necessary, but it is not a general action for every client in active labor. The need for cervical checks should be individualized based on the client's progress, preferences, and clinical indications.

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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?

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Naxlex Comprehensive Predictor Exams

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