A laboring patient reports, anxiety, vomiting, and the need to have a bowel movement. What is the expected cervical examination finding?

6 cm dilated and 80% effaced

8 cm dilated and 100% effaced

5 cm dilated and 70% effaced

Unmeasurable

Answer and Explanation

The Correct Answer is B

A. 6 cm dilated and 80% effaced – Incorrect; this is more consistent with active labor, but the symptoms suggest transition phase.
B. 8 cm dilated and 100% effaced – Correct; the transition phase (8-10 cm dilation) is characterized by intense contractions, nausea, and the sensation of rectal pressure.
C. 5 cm dilated and 70% effaced – Incorrect; this is too early for the transition phase symptoms.
D. Unmeasurable – Incorrect; cervical dilation and effacement can always be measured during labor unless obstructed by fetal descent.

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Correct Answer is A

Explanation

A. Lightening – Correct; "lightening" occurs when the fetal head descends into the pelvis, reducing pressure on the diaphragm, making it easier to breathe.

B. Decreasing chest diameter – Incorrect; the chest diameter does not decrease; instead, the diaphragm moves upward due to uterine growth.

C. Decreased carbon dioxide production – Incorrect; CO₂ production remains stable during pregnancy.

D. Hyperventilation – Incorrect; while pregnancy increases respiratory effort, the client is experiencing relief, not hyperventilation.

A. Notify social services. B. Ask the parents what caused the bruises. C. Ask the toddler what caused the bruises. D. Notify the provider.

Correct Answer is B

Explanation

A. Notify social services. – Incorrect; while reporting may be necessary, the nurse must first gather more information.

B. Ask the parents what caused the bruises. – Correct; the nurse should first assess by asking the parents in a nonjudgmental manner to determine if the bruises are accidental or suspicious for abuse.

C. Ask the toddler what caused the bruises. – Incorrect; toddlers may have limited verbal skills, and their responses may not be reliable.

D. Notify the provider. – Incorrect; while the provider should be informed, the nurse must first assess before escalating concerns.

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A laboring patient reports, anxiety, vomiting, and the need to have a bowel movement. What is the expected cervical examination finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is bathing a toddler and notices the child has several bruises. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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