Author Question: The perinatal nurse obtains valuable information from a vaginal examination. Which of the following ... (Read 43 times)

mwit1967 · **on:** Jun 28, 2018

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

Question 2

The perinatal nurse knows that changes in the pelvic floor musculature that normally occur in labor include which of the following? (Select all that apply.)

A.
Eversion of the anus
B.
Exposure of the internal rectal wall
C.
Pulling downward on the levator ani muscles
D.
Rectum drawn upward and backward
E.
Thinning of the perineal body

Sarahjh · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

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.

Answer to Question 2

ANS: A, B, E
Uterine contractions bring about changes in the pelvic floor musculature. The forces of labor cause the levator ani muscles and fascia of the pelvic floor to draw the rectum and vagina upward and forward. During descent, the fetal head exerts increasing pressure and causes thinning of the perineal body from 5 cm to less than 1 cm in thickness. Continued pressure causes the maternal anus to evert, and the interior rectal wall is exposed as the fetal head descends forward.