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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Washing the cord daily with mild soap and water is not recommended as it can delay healing and increase the risk of infection.
Choice B rationale:
Applying petroleum jelly to the cord stump is not recommended as it can create a moist environment that promotes bacterial growth.
Choice C rationale:
The diaper should be folded down to keep the cord stump dry and exposed to air, which promotes healing.
Choice D rationale:
Giving a sponge bath until the cord stump falls off is recommended to keep the area dry and prevent infection.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Heart rate and respiratory effort are two of the five parameters of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice B rationale:
Temperature is not a parameter of the Apgar score. Tone is a parameter, but this choice is incomplete as it does not include all five parameters.
Choice C rationale:
Color is a parameter of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice D rationale:
The Apgar score is based on five parameters: heart rate, breaths per minute (respiratory effort), irritability (response to stimulation), tone (muscle tone), and color. Therefore, this choice is correct.
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