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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Correct Answer is C
Explanation
A. Observe for the presence of a nuchal cord: While this is important, it is not specifically related to the finding of the fetal head at a certain station.
B. Prepare to administer oxytocin: Oxytocin is a hormone used to induce or augment labor, but there is no indication for its use based solely on the fetal head station.
C. Observe for crowning: The fetal head at 3+ station indicates significant descent, and crowning may occur soon. Crowning is the appearance of the fetal head at the vaginal opening and indicates that delivery is imminent.
D. Apply fundal pressure: Fundal pressure is not appropriate at this stage of labor and could cause harm.
Correct Answer is C
Explanation
Choice A: While relaxation can be helpful during a pelvic examination, it is not the most comprehensive response to address the client's concerns.
Choice B: A pelvic examination is not always required for prescribing birth control pills. In many cases, a healthcare provider can prescribe oral contraceptives based on the client's medical history and other factors without a pelvic exam.
Choice C: This response encourages the client to express her specific concerns and fears related to the examination, allowing the nurse to address them directly and provide appropriate support and reassurance.
Choice D: Although offering support during the exam is important, it does not address the client's nervousness and concerns about the examination itself.
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