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 A

Explanation

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

A. Active herpes simplex infection. B. Chronic cocaine use. C. Folic acid deficiency. D. Chronic alcohol use. E. Folic acid deficiency.

Correct Answer is D

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a postpartum woman.Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

Correct Answer is A

Explanation

A woman gives birth to a small infant with a malformed skull. The infant grows abnormally slowly and shows signs of substantial cognitive and intellectual deficits. The child also has facial abnormalities including a short nose and thin lip that become more striking as it develops.

Correct Answer is D

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