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:
Massaging the uterus does not increase its boggy nature, but rather helps it contract and become firm, reducing the risk of postpartum hemorrhage.
Choice B rationale:
Massaging the uterus helps constrict the uterine blood vessels, which reduces bleeding after the placenta has been expelled.
Choice C rationale:
Massaging the uterus has no effect on the likelihood of conducting an episiotomy, which is a surgical incision made during childbirth.
Choice D rationale:
Massaging the uterus does not remove pieces left attached to the uterine wall. This would require a manual or surgical procedure.
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.
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