The perinatal nurse obtains valuable information from a vaginal examination. Which of the following assessments from this examination should the nurse document? (Select all that apply.)
A.
Extent of cervical dilation
B.
Fetal presentation
C.
Presence of cervical effacement
D.
Status of the amniotic membranes
E.
Strength of uterine contractions
ANS: A, B, C, D
The vaginal examination provides important information regarding the diameter of the opening of the cervix, which ranges from 1 cm (not dilated) to 10 cm (fully dilated); the status of the amniotic membranes (ruptured or intact); and the fetal presentation and the station or the extent of the fetal descent through the maternal pelvis. A trained examiner can also assess effacement of the cervix during a vaginal exam.
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