A nurse on the labor and delivery unit is caring for a patient 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 below the ischial spines

The presenting part is 1 cm above the ischial spines

The cervix is 1 cm dilated .

Answer and Explanation

The Correct Answer is C

Choice A rationale
The term “effaced” refers to the thinning of the cervix, which is a process that occurs as labor approaches. However, the documentation “-1” does not indicate the degree of cervical effacement.
Choice B rationale
The term “presenting part is 1 cm below the ischial spines” would be documented as “+1” in a vaginal examination. This indicates that the presenting part of the fetus (usually the head) is 1 cm below the ischial spines, which are bony landmarks in the maternal pelvis.
Choice C rationale
The documentation “-1” in a vaginal examination refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis. A “-1” indicates that the presenting part is 1 cm above the ischial spines. This is a common finding during labor and does not indicate any abnormality.
Choice D rationale
The term “dilated” refers to the opening of the cervix. In the context of labor and delivery, the cervix dilates from 0 to 10 cm to allow for the passage of the baby. However, the documentation “-1” does not provide information about the degree of cervical dilation.

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Correct Answer is ["C","D","E"]

Explanation

The correct answers are Choices C, D, and E.
Choice A rationale
Fetal neck translucency is not typically evaluated during a biophysical profile. It is usually assessed during a first trimester ultrasound to screen for chromosomal abnormalities.
Choice B rationale
Fetal gender is not typically evaluated during a biophysical profile. The focus of a biophysical profile is on assessing the health and well-being of the fetus.
Choice C rationale
Fetal motion is one of the aspects evaluated during a biophysical profile. It is assessed to determine the activity level of the fetus.
Choice D rationale
Fetal breathing is one of the aspects evaluated during a biophysical profile. It is assessed to determine the respiratory function of the fetus.
Choice E rationale
Amniotic fluid volume is one of the aspects evaluated during a biophysical profile. It is assessed to determine the amount of amniotic fluid surrounding the fetus.

A. 3 cm above the umbilicus. B. 3 cm below the umbilicus. C. Slightly below the umbilicus. D. Slightly above the umbilicus. E. Answer and explanation

Correct Answer is D

Explanation

The correct answer is D. Slightly above the umbilicus. At 22 weeks of gestation, the fundus, or top of the uterus, is typically located slightly above the umbilicus.

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A nurse on the labor and delivery unit is caring for a patient 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 patient who is about to undergo a biophysical profile. The patient asks the nurse what aspects are evaluated during this test. Which of the following should the nurse include? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is D

Explanation

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