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 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.

A. "This could result in profound bleeding.” B. "There is an increased risk of introducing infection.” C. "This could initiate preterm labor.” D. "There is an increased risk of rupture of the amniotic membranes.”.

Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

An internal examination could disturb the placenta and cause profound bleeding, which is a life-threatening condition for both the mother and the fetus.

Choice B rationale:

While there is always a risk of introducing infection during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

Choice C rationale:

An internal examination could potentially initiate preterm labor, but this is not the primary concern with placenta previa.

Choice D rationale:

While there is a risk of rupture of the amniotic membranes during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

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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

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

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Correct Answer is A

Explanation

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