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 ["A","E","F"]
Explanation
The correct answers are choices B, E, and F.
Choice A rationale:
Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.
Choice B rationale:
Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.
Choice C rationale:
Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.
Choice D rationale:
Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.
Choice E rationale:
Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.
Choice F rationale:
Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
Fetal heart tones detected by ultrasound are a positive sign of pregnancy because they provide direct evidence of a fetus.
Choice B rationale:
Breast tenderness is a presumptive sign of pregnancy, not a positive one, as it can be caused by other conditions such as premenstrual syndrome.
Choice C rationale:
A positive urine pregnancy test is a probable sign of pregnancy, not a positive one, as it measures the presence of hCG, a hormone produced during pregnancy. However, certain medications and medical conditions can also produce hCG.
Choice D rationale:
Fatigue is a presumptive sign of pregnancy, not a positive one, as it can be caused by various other conditions such as stress or illness.
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