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The nurse has received report regarding her patient in labor. The woman's last vaginal examination was recorded as 3 cm, 30%, and ?2-2. The nurse's interpretation of this assessment is that:
a. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines.
b. The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines.
c. The cervix is effaced 3 cm, it
is dilated 30%, and the presenting part is 2 cm below the ischial spines.
d. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines.
The second stage of labor is the stage in which the infant is born.
This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth.
The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth.
The median duration of this stage of labor is 50 to 60 minutes in nulliparous clients and 20 to 30 minutes in multiparous clients.
During the second stage of labor, the infant is born; this stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth. The median duration of second-stage labor is 50 to 60 minutes in nulliparous clients and 20 to 30 minutes in multiparous clients. In the first stage of labor, the birthing table is usually not set up for the nulliparous client, and the progress of labor is enhanced when a client changes her position frequently.
Ans: 2
Option 1:
The infant will get 2 points for respiratory effort due to the good cry, 1 point for the heart rate below 100bpm, 2 points for active motion in muscle tone, 2 points for the vigorous cry in reflex activity, and 1 point for the acrocyanosis. The total is less than 10.
Option 2:
The infant will get 2 points for respiratory effort due to the good cry, 1 point for the heart rate below 100bpm, 2 points for active
motion in muscle tone, 2 points for the vigorous cry in reflex activity, and 1 point for the acrocyanosis. The total is 8.
Option 3:
The infant will get 2 points for respiratory effort due to the good cry, 1 point for the heart rate below 100bpm, 2 points for active motion in muscle tone, 2 points for the vigorous cry in reflex activity, and 1 point for the acrocyanosis. The total is less than 9.
Option 4:
The infant will get 2 points for respiratory effort due to the good cry, 1
point for the heart rate below 100bpm, 2 points for active motion in muscle tone, 2 points for the vigorous cry in reflex activity, and 1 point for the acrocyanosis. The total is more than 7.
Question 39. Following a vaginal exam on a client in labor, the nurse documents the client to be 8cm, 80%, +1. Which do these terms represent?
1.
Cervical effacement, fetal station, cervical dilation
2.
Cervical effacement, dilation, fetal
station
3.
Fetal station, cervical dilation, cervical effacement
4.
Cervical dilation, effacement, fetal station
Ans: 1,2,4,5
Option 1:
Lab values, especially for bleeding or clotting, should be checked for abnormalities.
Option 2:
Time-out verification procedures ensure client safety by identifying the client, the procedure to be done, any allergies or medical conditions, and the fire score.
Option 3:
Research does not support
mandating that the woman be a specific dilation prior to receiving an epidural. It is based on client preference.
Option 4:
The client must be informed of the risks and benefits of the procedure, as well as any alternatives by the anesthesiologist, before signing the consent. The consent must be signed to perform the invasive procedure.
Option 5:
Administration of an IV fluid bolus is important in preventing post-epidural hypotension.
Ans:1,2,3,5
Option 1:
In absence of any complications, allowing the labor to start on its own is supportive of normal, physiologic birth.
Option 2:
The World Health Organization and Lamaze International identified six birth practices that support and promote normal physiologic birth, including freedom of movement throughout labor.
Option 3:
The World Health Organization and Lamaze International identified six birth practices that support and promote normal physiologic birth, including
continuous support from family, friends, doulas, or nursing staff.
Option 4:
The World Health Organization and Lamaze International identified six birth practices that support and promote normal physiologic birth, including spontaneous pushing in non-supine positions.
Option 5:
The World Health Organization and Lamaze International identified six birth practices that support and promote normal physiologic birth, including minimizing interventions.