An assessment finding that would indicate to the nurse that ...

[cherise1989]

An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is:
 
  a. onset of irregular contractions.
  b. cephalic presentation at 0 station.
  c. bloody mucus drainage from vagina.
  d. fetal heart tones (FHTs) present in the lower right quadrant.

Question 2

On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time?
 
  a. Perform a vaginal exam to denote progress.
  b. Notify the health care provider.
  c. Initiate parenteral therapy.
  d. Apply oxygen via nasal cannula at 8 L/min.

[tjayeee]

Answer to Question 1

ANS: C
Cervical dilation and/or effacement results in loss of the mucous plug as well as rupture of small capillaries in the cervix; irregular contractions, cephalic presentation, and FHTs in the lower right quadrant do not indicate the onset of cervical ripening.

Answer to Question 2

ANS: B
A transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated. The information provided relative to transverse lie was found on vaginal exam. At this point, the priority is to prepare for a surgical birth because assessment data also indicate that the client is in early labor; thus, a vaginal birth is not imminent. Although initiating parenteral therapy will be required, it is not the priority at this time. Application of oxygen is not required because there is no evidence of fetal or maternal distress.

[cherise1989]

Thank you

[tjayeee]

No problemo