A nurse on the labor and delivery unit is caring for a patient 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 cervix is effaced 1 cm
The presenting part is 1 cm below the ischial spines
The presenting part is 1 cm above the ischial spines
The cervix is 1 cm dilated .
The Correct Answer is C
Choice A rationale
The term “effaced” refers to the thinning of the cervix, which is a process that occurs as labor approaches. However, the documentation “-1” does not indicate the degree of cervical effacement.
Choice B rationale
The term “presenting part is 1 cm below the ischial spines” would be documented as “+1” in a vaginal examination. This indicates that the presenting part of the fetus (usually the head) is 1 cm below the ischial spines, which are bony landmarks in the maternal pelvis.
Choice C rationale
The documentation “-1” in a vaginal examination refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis. A “-1” indicates that the presenting part is 1 cm above the ischial spines. This is a common finding during labor and does not indicate any abnormality.
Choice D rationale
The term “dilated” refers to the opening of the cervix. In the context of labor and delivery, the cervix dilates from 0 to 10 cm to allow for the passage of the baby. However, the documentation “-1” does not provide information about the degree of cervical dilation.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is []
Explanation
The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.
Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.
Correct Answer is A
Explanation
Choice A rationale
The client’s symptoms of headache, dizziness, blurred vision, 3+ edema in lower extremities, deep tendon reflexes (DTRs) 3+ with positive clonus, and a fetal heart rate (FHR) of 140 with minimal variability are indicative of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. It usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious complications for both the mother and baby. To address this condition, the nurse should: Monitor the client’s blood pressure regularly. Administer prescribed medications to control blood pressure and prevent seizures. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Chronic hypertension is a possibility, but it does not fully explain the client’s symptoms. While chronic hypertension can cause headaches and dizziness, it does not typically cause 3+ edema in the lower extremities or positive clonus. Furthermore, chronic hypertension would have been present before the pregnancy or diagnosed before the client reached 20 weeks of gestation.
Choice C rationale
While the client’s symptoms of headache, dizziness, and blurred vision could suggest a neurologic issue, the presence of 3+ edema in the lower extremities and positive clonus are more indicative of preeclampsia. Neurologic status would be monitored as part of the care for a client with preeclampsia.
Choice D rationale
Liver function studies would be relevant if there were symptoms or signs suggesting liver involvement such as upper right abdominal pain, nausea or vomiting, or jaundice. However, the client’s symptoms are more indicative of preeclampsia.
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