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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: This response is dismissive and does not validate the client's feelings. It may not address the client's concerns effectively.
Choice B: This response validates the client's feelings and reassures her that ambivalent feelings about pregnancy are common. It provides a supportive approach and normalizes her emotions.
Choice C: While counseling might be helpful for some clients, suggesting it immediately without further assessment of the client's needs may not be the most appropriate response at this stage.
Choice D: Encouraging the client to discuss her feelings with her mother may not be suitable, as the client might prefer professional support or may not have a positive relationship with her
mother. It is essential to avoid making assumptions about the client's support system and address her concerns empathetically.
Correct Answer is A
Explanation
A) Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B) Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C) Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D) Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.
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