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 presenting part is 1 cm above the ischial spines.

The cervix is effaced 1 cm.

The cervix is 1 cm dilated.

The presenting part is 1 cm below the ischial spines.

Answer and Explanation

The Correct Answer is C

The correct answer is: c. The cervix is 1 cm dilated.

Choice A reason:

The presenting part is 1 cm above the ischial spines. This statement would be documented as -1 station. Fetal station is measured in centimeters relative to the ischial spines, with negative numbers indicating the presenting part is above the spines.

Choice B reason:

The cervix is effaced 1 cm. Effacement is measured in percentages, not centimeters. It refers to the thinning of the cervix, which progresses from 0% (not effaced) to 100% (fully effaced).

Choice C reason:

The cervix is 1 cm dilated. This means the cervix has opened 1 cm, which is a common measurement during early labor. Cervical dilation ranges from 0 cm (closed) to 10 cm (fully dilated).

Choice D reason:

The presenting part is 1 cm below the ischial spines. This would be documented as +1 station. Positive numbers indicate the presenting part is below the ischial spines, moving towards delivery.

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Correct Answer is B

Explanation

Choice A: Elevating the client's legs is a measure to increase blood flow to the brain in cases of orthostatic hypotension but may not be sufficient to improve fetal oxygenation in this situation. The lateral position is preferred as it improves uterine perfusion.

Choice B: The client's blood pressure of 80/40 mm Hg indicates hypotension, which can be a common side effect of epidural anesthesia. The priority nursing action is to place the client in a lateral (sidelying) position to improve blood flow to vital organs, including the uterus and placenta, and prevent further compromise of fetal oxygenation.

Choice C: Monitoring vital signs every 5 minutes is an important nursing action, but the priority in this situation is to address the hypotension and improve maternal and fetal wellbeing first.

Choice D: Notifying the provider is an important step, but it should not be the first action. Immediate intervention to address the hypotension is required to improve fetal oxygenation.

A. The client requires a rubella vaccination at this time. B. The client is not experiencing a rubella infection at this time. C. The client requires a rubella immunization following delivery. D. The client is immune to the rubella virus.

Correct Answer is C

Explanation

A. The client requires a rubella vaccination at this time. This is incorrect because rubella vaccination is contraindicated during pregnancy due to the risk of congenital rubella syndrome. Vaccination should be administered postpartum.

B. The client is not experiencing a rubella infection at this time. While this statement is true, it does not address the need for future immunization, which is the critical aspect of the interpretation.

C. The client requires a rubella immunization following delivery. This is correct because a negative rubella titer indicates that the client is not immune to rubella and should receive the vaccine postpartum to prevent future infection.

D. The client is immune to the rubella virus. This is incorrect because a negative rubella titer indicates a lack of immunity to rubella, meaning the client is susceptible to infection.

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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 caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

Correct Answer is B

Explanation

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

Correct Answer is C

Explanation

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