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 posterior fontanel is palpable.
The lowermost portion of the fetus is at the level of the ischial spines.
The fetal head is in the left occiput posterior position.
The largest fetal diameter has passed through the pelvic outlet.
The Correct Answer is B
A) The posterior fontanel is palpable:
This statement is not directly related to station. The fontanelles are soft spots on the fetal skull used to assess fetal head position, but they are not specifically related to station.
B) The lowermost portion of the fetus is at the level of the ischial spines:
In obstetrics, station refers to the relationship between the presenting part of the fetus and the maternal ischial spines. When the presenting part is at 0 station, it means that the lowest part of the fetus (usually the head) is at the level of the maternal ischial spines. This is a significant landmark indicating the progress of labor. As labor progresses, the fetus descends further into the pelvis, with stations progressing from -3 to +3.
C) The fetal head is in the left occiput posterior position:
The station does not provide information about the fetal head position. Left occiput posterior position refers to the position of the fetal head in relation to the maternal pelvis, which is determined separately through pelvic examinations.
D) The largest fetal diameter has passed through the pelvic outlet:
While 0 station indicates engagement of the fetal head in the pelvis, it does not necessarily mean that the largest fetal diameter has passed through the pelvic outlet. Labor continues until the entire fetus is delivered through the birth canal, which occurs as labor progresses through the different stages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Contractions are strong in intensity: Strong contractions are expected during the active phase of the first stage of labor. While the nurse should monitor the strength of contractions, strong intensity alone is not typically a cause for concern during this phase.
B) Client reports feeling contractions in the lower back: Back pain during contractions is common, especially during the active phase of labor. It is often associated with the pressure of the baby's head on the sacral nerves. Although it can be uncomfortable, it is not typically a significant concern unless it is accompanied by other symptoms.
C) Contractions occurring every 3 to 5 minutes: This is a normal finding during the active phase of the first stage of labor. Contractions becoming more regular and frequent are expected as labor progresses.
D) Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can be detrimental to both the mother and the fetus. Uterine hyperstimulation can reduce placental perfusion, leading to fetal distress and maternal complications such as uterine rupture. Therefore, the nurse should report contractions lasting longer than 90 seconds to the provider for further evaluation and management.
Correct Answer is B
Explanation
A) Nausea: Nausea is a common side effect of magnesium sulfate therapy but is not necessarily indicative of magnesium sulfate toxicity. It is important to monitor for nausea, but it is not the most critical finding to indicate toxicity.
B) Respiratory depression: Respiratory depression is a severe sign of magnesium sulfate toxicity and should be reported to the provider immediately. Magnesium sulfate can depress the central nervous system, leading to respiratory depression, which is a potentially life-threatening complication.
C) Drowsiness: Drowsiness is a common side effect of magnesium sulfate therapy, especially at therapeutic levels. However, it is not necessarily indicative of magnesium sulfate toxicity. While drowsiness should be monitored, it is not as critical as respiratory depression in indicating toxicity.
D) Facial flushing: Facial flushing is a common side effect of magnesium sulfate therapy and is not typically associated with magnesium sulfate toxicity. While it can be uncomfortable for the patient, it is not a severe indication of toxicity compared to respiratory depression.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.