The nurse has received a report regarding her patient in labor.
The woman’s last vaginal examination was recorded as 3 cm, 30%, and -2. The nurse’s interpretation of this assessment is that:
The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines.
The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines.
The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below the ischial spines.
The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines.
The Correct Answer is B
Choice A rationale
The cervix is measured in dilation, not effacement, in centimeters. Effacement is expressed in percentage, indicating the thinning of the cervix.
Choice B rationale
The cervix is 3 cm dilated, 30% effaced, and the presenting part is 2 cm above the ischial spines. This assessment provides a clear status of labor progress.
Choice C rationale
The presenting part being below the ischial spines would be recorded with a positive station, indicating descent into the pelvis, unlike this assessment.
Choice D rationale
The cervix is assessed for dilation in centimeters and effacement in percentage, with station indicating the relationship to the ischial spines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Meconium is produced by the fetal intestines. The intestines start to form meconium around the 16th week of gestation. Meconium is composed of shed cells, mucus, amniotic fluid, bile, and lanugo.
Choice B rationale
The placenta does not produce meconium. Its primary functions include nutrient transfer, gas exchange, and waste elimination, but it does not have the structures necessary for the production of meconium.
Choice C rationale
Amniotic fluid does not produce meconium. Amniotic fluid surrounds and protects the fetus but does not contain the components needed to create meconium. Instead, the fetus swallows and then excretes it into the intestines.
Choice D rationale
Fetal kidneys are responsible for filtering waste and producing urine, but they do not produce meconium. The production of meconium is a function of the intestines, not the kidneys.
Correct Answer is B
Explanation
Choice A rationale
Fetal movement felt by the pregnant woman is a presumptive sign of pregnancy, indicating probable fetal presence, but not definitive evidence.
Choice B rationale
Fetal heart rate noted on ultrasound is a positive sign of pregnancy, providing objective evidence of fetal existence within the uterus.
Choice C rationale
A positive pregnancy test indicates probable pregnancy due to hormonal presence, but it is not a definitive confirmation without further clinical evidence.
Choice D rationale
Braxton Hicks contractions are considered probable signs of pregnancy, as they indicate uterine activity without confirming the presence of a fetus.
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