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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: "I should not drink alcoholic beverages during my pregnancy." Correct, as alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders and other adverse outcomes.
Choice B: "I should drink about 2 liters of fluid each day." Correct, as adequate hydration is essential during pregnancy.
Choice C: "I can have a moderate amount of caffeine daily." Correct, as moderate caffeine consumption is generally considered safe during pregnancy (around 200300 mg per day).
Choice D: During pregnancy, certain fish types can be high in mercury, which can be harmful to the developing fetus. Fish with high mercury levels should be limited or avoided during pregnancy.

A. The largest fetal diameter has passed through the pelvic outlet. B. The lowermost portion of the presenting part is at the level of the ischial spines. C. The posterior fontanel is palpable. D. The fetal head is in the left occiput posterior position.

Correct Answer is B

Explanation

A) The largest fetal diameter has passed through the pelvic outlet: This is an incorrect

interpretation of station 0. Station 0 means that the presenting part is at the level of the ischial spines, not fully descended through the pelvic outlet.

B) The lowermost portion of the presenting part is at the level of the ischial spines: This is the correct interpretation of station 0. Station 0 is the landmark at which the presenting part is at the level of the ischial spines in the maternal pelvis.
C) The posterior fontanel is palpable: The position of the fontanelle is not related to the station of the presenting part.
D) The fetal head is in the left occiput posterior position: The position of the fetal head is not indicated by the station measurement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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