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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Related Questions
Correct Answer is D
Explanation
Choice D: Leopold maneuvers are used to determine the fetal position and presentation by palpating the abdomen. ROA stands for Right Occiput Anterior, which means the baby's head is presenting and facing towards the mother's right side (Occiput) and positioned anteriorly (front of the pelvis).
This position is a common and favorable presentation for a vaginal delivery.
Choice A: Shoulder presentation is when the baby is presenting with the shoulder rather than the head. It is an abnormal presentation and requires a cesarean delivery.
Choice B: Mentum presentation is a type of face presentation, where the baby's chin (mentum) is presenting instead of the head. It is also an abnormal presentation and usually requires a cesarean delivery.
Choice C: Breech presentation is when the baby's buttocks or feet are presenting first instead of the head. It is another abnormal presentation that may require a cesarean delivery or careful vaginal delivery with a skilled healthcare provider.
Correct Answer is A
Explanation
A. Fetal position is persistent occiput posterior: The occiput posterior position (the back of
the baby's head facing the mother's back) can lead to a more challenging and prolonged labor with intense back pain.
B. Fetal attitude is in general flexion: Flexion is the normal fetal attitude for birth and does not contribute to a difficult labor with backache.
C. Fetal lie is longitudinal: Longitudinal lie refers to the baby's position along the mother's spine, but it doesn't specify the position of the baby's back, so it is not directly related to backache.
D. Maternal pelvis is gynecoid: Gynecoid pelvis is the most favorable pelvis shape for childbirth, so it is not likely to cause difficult labor with severe backache.
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