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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.3"]
Explanation
Step 1 is to identify the concentration of the medication. From the search results, enoxaparin comes in pre-filled syringes with different concentrations, one of which is 30 mg/0.3 mL56.
Step 2 is to calculate the volume to be administered. Since the client is due to receive 30 mg of enoxaparin and the concentration is 30 mg/0.3 mL, the calculation is (30 mg ÷ 30 mg) × 0.3 mL. The final calculated answer is 0.3 mL.
Correct Answer is A
Explanation
The correct answer is A. Shoulder dystocia. Retraction of the fetal head against the maternal perineum as the head is birthed is a classic sign of shoulder dystocia. This is a birth complication where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery.
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