1. A new mother asks the nurse when the "soft spot" on her son's head will go away. The nurse's answer
is based on the knowledge that the anterior fontanel closes after birth by _____ months.
a. 2
b. 8
c. 12
d. 18 - ANS ANS: D
The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth.
2. When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to
one another is called fetal:
a.
Lie.
b.
Presentation.
,c.
Attitude.
d.
Position. - ANS ANS: C
Attitude is the relation of the fetal body parts to one another. Lie is the relation of the long axis (spine)
of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters
the pelvic inlet first and leads through the birth canal during labor at term. Position is the relation of the
presenting part to the four quadrants of the mother's pelvis.
3. When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable fetal part
in the fundal portion of the uterus and a long, smooth surface in the mother's right side close to midline.
What is the likely position of the fetus?
a.
ROA
b.
LSP
c.
,RSA
d.
LOA - ANS ANS: C
The fetus is positioned anteriorly in the right side of the maternal pelvis with the sacrum as the
presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. The first letter
indicates the presenting part in either the right or left side of the maternal pelvis. The second letter
indicates the anatomic presenting part of the fetus. The third letter stands for the location of the
presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis.
Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head,
indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal
pelvis. Palpation of the fetal spine along the mother's right side denotes the location of the presenting
part in the mother's pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly
positioned in the maternal pelvis.
4. 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 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).
5. To care for a laboring woman adequately, the nurse understands that the __________ stage of labor
varies the most in length?
a.
First
b.
Second
c.
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