The nurse has received a report regarding her patient in labor. The woman's last vaginal examination was recorded as 2 cm, 80%, and +2. The nurse's interpretation of this assessment is that:
Select one:
The cervix is dilated 2 cm, it is effaced 80%, and the presenting part is 2 inches below the ischial spines.
The cervix is 2 cm dilated, it is effaced 80%, and the presenting part is 2 cm above the ischial spines.
The cervix is dilated 2 cm, it is effaced 80%, and the presenting part is 2 cm below the ischial spines.
The cervix is effaced 2 cm, it is dilated 80%, and the presenting part is 2 cm above the ischial spines.
The Correct Answer is C
a. This is an incorrect interpretation of the assessment.
b. This is an incorrect interpretation of the assessment.
c. This is the correct interpretation of the assessment indicating that the labor is progressing well and the baby is descending into the pelvis.
d. This is an incorrect interpretation of the assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. A posterior presentation is when the fetus's back is toward the mother's back, and the fetal heart tones are usually heard on either side of the mother's abdomen.
b. A breech presentation is when the fetus's buttocks or feet are closest to the cervix. The fetal heart tones are usually heard above the umbilicus, at the midline, in a breech presentation.
c. A cephalic presentation is when the fetus's head is closest to the cervix, and the fetal heart tones are usually heard below the umbilicus, in either quadrant.
d. An oblique presentation is when the fetus's head or buttocks are angled toward one side of the pelvis, and the fetal heart tones are usually heard off-center, above or below the umbilicus.
e. A transverse presentation is when the fetus's spine is perpendicular to the mother's spine, and the fetal heart tones are usually heard on one side of the abdomen.
Correct Answer is A
Explanation
a. Anasarca, which refers to generalized edema or swelling, can be a sign of a serious medical condition such as preeclampsia or heart failure and should prompt immediate medical evaluation.
b. Morning vomiting is a common discomfort in the first trimester of pregnancy and typically does not require immediate medical attention unless it is severe or persistent.
c. Braxton Hicks contractions, which are mild and irregular contractions that can occur throughout pregnancy, are typically not a cause for concern.
d. Frequent urination is a common discomfort in the first trimester of pregnancy and typically does not require immediate medical attention unless it is accompanied by other symptoms.
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