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 C
Explanation
The correct answer is choice C.
Choice A rationale:
While it’s important to monitor a newborn’s glucose level, it’s not the immediate priority following birth.
Choice B rationale:
Placing the infant in the bassinet is not the immediate priority. The newborn needs to be dried and warmed first to prevent hypothermia.
Choice C rationale:
Drying the newborn and placing it skin-to-skin on the mother helps prevent hypothermia and promotes bonding. This is the immediate priority.
Choice D rationale:
A full head-to-toe assessment is important, but it’s not the immediate priority following birth.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Superficial structures above the muscle refer to first-degree lacerations, which only involve the skin of the perineum and vaginal mucosa.
Choice B rationale:
A fourth-degree laceration does not stop at the anterior rectal wall. It extends through the anal sphincter and into the rectal mucosa.
Choice C rationale:
While a fourth-degree laceration does involve the anal sphincter muscle, it also includes the underlying rectal mucosa.
Choice D rationale:
A fourth-degree laceration involves the perineal muscles, the anal sphincter, and the underlying rectal mucosa.
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