A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?
The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines.
The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines.
The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines.
The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.
The Correct Answer is D
The cervix is dilated 3 cm: This indicates the width of the cervical opening, which is 3 cm wide.
It is effaced 30%: This means the cervix has effaced or thinned out by 30%, indicating how much the cervix has shortened and thinned in preparation for labor.
The presenting part is 1 cm above the ischial spines (indicated by the negative number, -1): This measurement shows the position of the baby's head in relation to the ischial spines of the pelvis. In this case, the baby's head is 1 cm above the ischial spines.
Option A ("The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines."): This option incorrectly interprets the baby's position as being 1 cm below the ischial spines, which is not the case. The negative sign (-1) in the documentation indicates that the presenting part is 1 cm above the ischial spines.
Option B ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines."): This option switches the interpretation of dilation and effacement. In the original documentation, the dilation is given as 3 cm, while effacement is 30%. This option incorrectly states that effacement is 3 cm and dilation is 30%. Additionally, it correctly identifies the presenting part's position.
Option C ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines."): This option correctly interprets effacement and dilation but incorrectly states that the presenting part is 1 cm below the ischial spines. The original documentation indicates that the presenting part is 1 cm above the ischial spines, as denoted by the negative sign (-1).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
The nurse should report the blood pressure findings to the provider because there is a significant increase in both systolic and diastolic blood pressure. At 0900, the blood pressure was 156/90 mm Hg, and at 1000, it increased to 160/96 mm Hg. This significant elevation in blood pressure can be a cause for concern as it may indicate the development of gestational hypertension or preeclampsia, which can be dangerous for both the client and the fetus.
Choice B rationale:
Cerebral manifestations are not mentioned in the nurse's notes or vital signs and are not relevant to the given scenario. Therefore, this choice is not applicable in this case.
Choice C rationale:
The nurse should report the fetal heart rate findings to the provider because it is not included in the vital signs section of the nurse's notes. Monitoring the fetal heart rate is essential to ensure the well-being of the fetus, and any abnormalities or changes in the fetal heart rate should be promptly reported to the healthcare provider for further evaluation.
Choice D rationale:
The nurse should report the respiratory rate findings to the provider. Although the respiratory rate seems to be within the normal range (22/min at 0900 and 21/min at 1000), it is a vital sign that should be closely monitored in pregnant clients. Any sudden changes or abnormalities in the respiratory rate may indicate respiratory distress or other health issues that need medical attention. Choices E and F rationale: Deep tendon reflexes and gastrointestinal assessment findings are not mentioned in the nurse's notes or vital signs. These options are not applicable in this scenario and do not require reporting to the provider.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should include teaching the client to perform daily fetal movement counts because it is an essential aspect of monitoring the baby's well-being and assessing fetal distress. Fetal movement counts help the client become familiar with their baby's normal patterns of movement, allowing them to detect any changes or decreased movements promptly. This can be crucial in identifying potential issues with the baby's health and seeking timely medical attention.
Choice B rationale:
The nurse should not advise limiting fluid intake to 1,000 mL/day for a client with mild preeclampsia. Adequate hydration is important during pregnancy, and excessive fluid restriction can lead to dehydration, which is harmful to both the mother and the baby. Preeclampsia can cause fluid retention and high blood pressure, but complete fluid restriction is not the appropriate approach for managing the condition.
Choice C rationale:
The nurse should not suggest limiting sodium intake to 2,000 mg/day for a client with mild preeclampsia. While reducing sodium intake can be beneficial for some individuals with hypertension, it is not the primary focus in managing mild preeclampsia. The mainstay of treatment for mild preeclampsia typically involves close monitoring, rest, and potential medications to control blood pressure if necessary.
Choice D rationale:
The nurse should not recommend that the client rest in bed in the supine position. During pregnancy, especially with preeclampsia, lying flat on the back (supine position) can lead to a condition called supine hypotensive syndrome. This occurs when the weight of the uterus presses on the vena cava, reducing blood flow back to the heart and potentially causing a drop in blood pressure and decreased blood flow to the baby.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.