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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administering oxygen at 10 L/min via a nonrebreather mask is an important intervention, but changing the client's position is the priority action when late decelerations are observed. Oxygen administration can follow, but optimizing uteroplacental perfusion through changing position is crucial.
B. Changing the client's position is the correct first action.
Repositioning the client, particularly from a supine to a side-lying position, can help alleviate compression on the vena cava and improve blood flow to the uterus, reducing the likelihood of late decelerations.
C. Applying a fetal scalp electrode is not the initial action when late decelerations are noted. Repositioning the client should be attempted first to address potential issues related to uteroplacental perfusion.
D. Increasing the rate of the intravenous (IV) infusion might not directly address the issue of late decelerations. It's important to focus on maternal positioning first to improve blood flow to the uterus.
Correct Answer is A
Explanation
A. Correct. In rapidly progressing labor, applying gentle perineal pressure helps control the speed of delivery and can prevent or minimize perineal tearing or lacerations. It also helps to manage the delivery of the fetal head, especially in cases where the labor is very rapid which can cause neurologic damage (increased intracranial pressure and dural/subdural tearing).
B. Cutting the umbilical cord is not the priority in this situation. The focus should be on the immediate management of the delivery process and preventing complications related to perineal tearing.
C. Preventing the perineum from tearing: While preventing the perineum from tearing is important, it is not the immediate priority in the context of rapidly progressing labor. The primary focus should be on safely delivering the baby, which involves controlling the delivery of the fetal head to prevent complications.
D. Promoting the delivery of the placenta is a consideration for the third stage of labor, which follows the delivery of the baby. It is not the priority during the active phase of delivery.
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