A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?
The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines.
The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines.
The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines.
The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.
The Correct Answer is D
The cervix is dilated 3 cm: This indicates the width of the cervical opening, which is 3 cm wide.
It is effaced 30%: This means the cervix has effaced or thinned out by 30%, indicating how much the cervix has shortened and thinned in preparation for labor.
The presenting part is 1 cm above the ischial spines (indicated by the negative number, -1): This measurement shows the position of the baby's head in relation to the ischial spines of the pelvis. In this case, the baby's head is 1 cm above the ischial spines.
Option A ("The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines."): This option incorrectly interprets the baby's position as being 1 cm below the ischial spines, which is not the case. The negative sign (-1) in the documentation indicates that the presenting part is 1 cm above the ischial spines.
Option B ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines."): This option switches the interpretation of dilation and effacement. In the original documentation, the dilation is given as 3 cm, while effacement is 30%. This option incorrectly states that effacement is 3 cm and dilation is 30%. Additionally, it correctly identifies the presenting part's position.
Option C ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines."): This option correctly interprets effacement and dilation but incorrectly states that the presenting part is 1 cm below the ischial spines. The original documentation indicates that the presenting part is 1 cm above the ischial spines, as denoted by the negative sign (-1).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The umbilical cord typically contains two arteries and one vein. Arteries carry oxygen-depleted blood and waste products from the fetus to the placenta for removal, while the vein carries oxygenated blood and nutrients from the placenta to the fetus. This arrangement is essential for maintaining proper fetal circulation during pregnancy.
Choice B rationale:
This choice is incorrect because the umbilical cord usually contains two arteries and one vein, not just one artery and one vein. Having only one artery could indicate a potential vascular abnormality or congenital issue that may require further investigation or medical attention.
Choice C rationale:
This is the correct answer. The umbilical cord usually contains two arteries and one vein. The presence of two arteries allows for the efficient removal of waste products and carbon dioxide from the fetus, while the single vein delivers essential nutrients and oxygen to support the baby's growth and development.
Choice D rationale:
This choice is incorrect as it states two veins and one artery, which is not the typical configuration of blood vessels in the umbilical cord. Having two veins and one artery would disrupt fetal circulation and hinder proper nutrient and waste exchange between the fetus and the placenta.
Correct Answer is B
Explanation
The correct answer is choice B: “You must be feeling very scared.” This response is an example of therapeutic communication, where the nurse acknowledges the client’s feelings and provides emotional support without making assumptions or giving false reassurances.
Choice A rationale: While it’s true that the presence of a neonatal unit equipped to handle emergencies is reassuring, this response does not address the client’s immediate emotional needs or fears. It’s important for the nurse to recognize and validate the client’s feelings rather than focusing solely on the facilities available.
Choice B rationale: This choice demonstrates empathy and understanding. It allows the client to express their feelings and concerns, which is a crucial aspect of providing emotional support during labor. By acknowledging the client’s potential fear, the nurse opens the door for further communication and support.
Choice C rationale: This response minimizes the client’s individual feelings by suggesting that everyone has the same worries. It can make the client feel that their concerns are not unique or taken seriously, which is not conducive to establishing trust or providing individualized care.
Choice D rationale: This choice provides false reassurance. At 32 weeks of gestation, while the prognosis for the baby is generally good, there are still risks associated with preterm birth. It’s important not to make definitive statements about outcomes that cannot be guaranteed.
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