A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider, which is documented as: 1/50%/-2. 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.
None
None
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:
In obstetrics, a sterile vaginal exam (SVE) is recorded using a standard three-part shorthand: Dilation / Effacement / Station. Dilation: This is always the first number in the sequence. It measures the opening of the cervix from 0 to 10 centimeters. Therefore, if the finding begins with the number 1, it indicates the cervix has opened to a diameter of 1 cm.
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 D
Explanation
A) A reactive test: A reactive NST requires the presence of specific criteria, including at least two fetal heart rate accelerations of at least 15 beats per minute (bpm) lasting for at least 15
seconds in a 20minute period, along with a baseline heart rate within the normal range (110160 bpm) and moderate variability.
B) A negative test: "Negative" is not a term used to describe NST results.
C) A positive test: "Positive" is not a term used to describe NST results.
D) A nonreactive test: This is the correct interpretation. In a nonreactive NST, the fetal heart rate did not demonstrate the required accelerations within the 30minute observation period. The absence of accelerations can indicate potential fetal compromise, and further evaluation, such as a contraction stress test or biophysical profile, may be necessary to assess the fetus's wellbeing.
Correct Answer is A
Explanation
Choice A:The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
Choice B: Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
Choice C: Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
Choice D: Palpating the client's uterus is not the first priority in the presence of late
decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.
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