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
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Abdominal pain accompanied by minimal red vaginal bleeding is not a typical symptom of placenta previa. In placenta previa, the placenta covers all or part of the cervix, which can cause severe bleeding. However, this bleeding is typically not associated with abdominal pain.
Choice B rationale
Intermittent abdominal pain following the passage of bloody mucus is not a common symptom of placenta previa. This symptom is more commonly associated with labor or other conditions, but not specifically with placenta previa.
Choice C rationale
Increasing abdominal pain with a nonrelaxed uterus is not a typical symptom of placenta previa. This could be a sign of other complications such as uterine rupture or placental abruption, which are serious conditions that require immediate medical attention.
Choice D rationale
Painless red vaginal bleeding is indeed a symptom of placenta previa. This bleeding is usually bright red and can occur intermittently or continuously. It is most common in the third trimester of pregnancy.
Correct Answer is C
Explanation
Choice A reason:
Fetal head compression is associated with early decelerations, not late. Early decelerations are a normal finding during labor as the fetal head is compressed during contractions, leading to a vagal response that temporarily decreases the heart rate.
Choice B reason:
Umbilical cord compression leads to variable decelerations, not late. Variable decelerations can occur at any time during the contraction cycle and are caused by compression of the umbilical cord, which can restrict blood flow to the fetus.
The correct answer is C. Uteroplacental insufficiency.
Late decelerations are indicative of uteroplacental insufficiency, which is a condition where the placenta is not delivering enough oxygen and nutrients to the fetus.
Choice D reason:
Maternal bradycardia, which is a slower than normal heart rate in the mother, does not cause late decelerations in the fetus. Instead, maternal bradycardia can be a separate concern and does not directly affect the fetal heart rate pattern observed on the monitor.
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