A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

The cervix is effaced 1 cm.

The presenting part is 1 cm above the ischial spines.

The cervix is 1 cm dilated.

The presenting part is 1 cm below the ischial spines.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B.

Choice A rationale:

The term “-1” in a vaginal examination does not refer to the effacement of the cervix. Effacement is usually expressed as a percentage.

Choice B rationale:

In a vaginal examination, “-1” refers to the station of the fetus. A “-1” station means that the presenting part of the fetus (usually the head) is 1 cm above the ischial spines.

Choice C rationale:

The term “-1” in a vaginal examination does not refer to the dilation of the cervix. Dilation is usually measured in centimeters, from 0 (no dilation) to 10 (fully dilated).

Choice D rationale:

A “-1” station does not mean that the presenting part is below the ischial spines. It means that it is above the ischial spines.

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Correct Answer is D

Explanation

The correct answer is choice D. When the cervix is fully dilated.

Choice A rationale:

The arrival of the health care provider does not determine when the laboring client should push. This is dependent on the dilation of the cervix.

Choice B rationale:

Seeing the fetal head is not the determinant for when the laboring client should push. The cervix needs to be fully dilated.

Choice C rationale:

The nurse wanting the client to push is not the correct time for the laboring client to push. The cervix needs to be fully dilated.

Choice D rationale:

The laboring client is encouraged to push when the cervix is fully dilated. This is to avoid birth trauma.

A. "I should keep my baby's head covered.” B. "My baby's bassinet should be kept away from fans and air conditioning.” C. "My baby's temperature will be checked rectally every hour.” D. "I should place my baby on my stomach and cover her with a warm blanket.”

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

Keeping the baby’s head covered helps to prevent heat loss, as newborns lose a significant amount of heat through their heads.

Choice B rationale:

Keeping the baby’s bassinet away from fans and air conditioning helps to maintain a stable body temperature.

Choice C rationale:

Newborns’ temperatures are typically checked every 3 to 4 hours, not every hour, and are usually done axillary, not rectally.

Choice D rationale:

Placing the baby on the mother’s stomach and covering her with a warm blanket promotes skin-to-skin contact and helps to maintain the baby’s body temperature.

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A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

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Naxlex Comprehensive Predictor Exams

At what time is the laboring client encouraged to push?

Correct Answer is D

Explanation

A nurse is providing teaching about newborn care to a client who is 2 hr postpartum.Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

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