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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Weightbearing exercises should be avoided or limited during pregnancy, as they can increase the risk of injury, joint pain, and fatigue.
B. Correct. Moderate exercise can improve circulation, reduce swelling, and prevent varicose veins during pregnancy.
C. Incorrect. Resting for 30 minutes before each new exercise is not necessary and may reduce the benefits of physical activity.
D. Incorrect. Stretching exercises can help prevent muscle cramps, improve flexibility, and reduce back pain during pregnancy.
Correct Answer is D
Explanation
The correct answer is: April 11, 2016
Choice A: April 27, 2016
Reason: Using Naegele’s Rule, the estimated date of delivery (EDD) is calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). For an LMP of May 4, 2015:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 27, 2016, is incorrect because it does not follow the correct calculation steps.
Choice B: April 11, 2016
Reason: Following Naegele’s Rule:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 11, 2016, is the correct EDD as it accurately follows the calculation steps.
Choice C: February 27, 2016
Reason: This date is incorrect because it does not follow the correct calculation steps of Naegele’s Rule. The correct EDD should be in April, not February.
Choice D: February 11, 2016
Reason: This date is also incorrect. While it follows the initial steps of Naegele’s Rule, it does not account for the full calculation, which should result in an April date, not February.
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