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    ATI NUR 209 Maternal Newborn Proctored Exam

    A first-time mother presents for a labor check.She is informed that her vaginal exam shows dilated (3 cm), effaced (100%), and fetal station (-2). What explanation is the most appropriate response by the nurse?

    Explanation & Rationale

    Choice A rationaleWhile a dilation of 3 cm indicates some cervical opening, stating the baby is "very low" with a station of -2 is inaccurate. A negative station indicates the presenting part is above the ischial spines, not low in the pelvis.Choice B rationaleA cervical effacement of 100% means the cervix has fully thinned out. A fetal station of -2 indicates the presenting part of the fetus is 2 cm above the ischial spines. Therefore, the cervix is completely thinned, and the baby's head is relatively high in the pelvis.Choice C rationaleAlthough the cervix is dilated to 3 cm, indicating some opening, the fetal station of -2 signifies that the baby is still high in the pelvis, not low. This statement correctly identifies the dilation but inaccurately describes the fetal descent.Choice D rationaleA cervical dilation of 3 cm indicates the cervix is open to some extent. However, the 100% effacement indicates that the cervix is already completely thinned out, so the statement that it "still needs to thin out" is incorrect.

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