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.
ANS: B
The correct description of the vaginal examination for this woman in labor is the cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below).
You might also like to view...
The nurse is an advocate for health promotion activities. Which nursing actions demonstrate this nurse's advocacy?
1. Participating in a community-focused 5-mile run. 2. Attending the local high school's football games. 3. Providing an educational program to senior citizens on blood pressure–control strategies. 4. Attending a community meeting that is promoting the creating of a walking path in the city park. 5. Encouraging an anxious client to practice relaxation techniques.
The community health nurse will be analyzing community assessment data. Which of the following is an example of demographic characteristics?
A) Number and size of neighborhoods B) Occupation and income categories C) Rental or home ownership patterns D) Sex and family size
A patient has been in the intensive care unit for a week receiving various procedures throughout the day and night. Currently the patient, though physiologically stable, is irritable and paranoid and complains of vivid dreams when dozing off to sleep
What are the best actions for the nurse to take at this time? 1. Check the patient's oxygen status. 2. Request an order for sleep medication. 3. Assess the patient's vital signs. 4. Turn down the lights at night and reduce noise to a minimum. 5. Schedule all tests and procedures before 9 p.m. or after 7 a.m.
The nurse prepares to remove a client's indwelling urinary catheter. Which technique will the nurse use when performing this procedure?
A. Aspirate the balloon vigorously. B. Withdraw all the fluid from the balloon. C. Detach the catheter from the client's skin. D. Use clean gloves instead of sterile gloves. E. Place a towel between the client's legs.