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 B
Explanation
The correct answer is choice B.
Choice A rationale:
Cabbage leaves have been used for many years for relief of breast engorgement. They can be crushed slightly until the juice is visible and then chilled in the refrigerator before applying to the breasts.
Choice B rationale:
Applying hot packs during feeding can actually increase blood flow and make engorgement worse. Cold packs should be used after feeding to help reduce swelling.
Choice C rationale:
Applying ice packs after feeding can help reduce swelling and provide relief from engorgement.
Choice D rationale:
Frequent breastfeeding can help to relieve engorgement. The breasts should be emptied completely at each feeding.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Abdominal pain with scant red vaginal bleeding is more indicative of placental abruption, not placenta previa.
Choice B rationale:
Painless red vaginal bleeding is a classic sign of placenta previa. This happens because the placenta is covering the cervix, which can lead to bleeding.
Choice C rationale:
Increasing abdominal pain with a nonrelaxed uterus is more indicative of a condition like uterine rupture or labor, not placenta previa.
Choice D rationale:
Intermittent abdominal pain following the passage of bloody mucus is more likely a sign of labor, not placenta previa.
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