A nurse is performing a digital examination on a client who is at 34 weeks of gestation and has pre-term labor.

Which of the following findings indicates cervical effacement?

Cervix is soft and pliable

Cervix is shortened and thinned

Cervix is dilated and open

Cervix is posterior and high

Answer and Explanation

The Correct Answer is B

Cervix is shortened and thinned. This indicates cervical effacement, which is the thinning and softening of the cervix in preparation for childbirth. Cervical effacement is measured in percentages, from 0% (no effacement) to 100% (fully effaced).

Choice A is wrong because cervix is soft and pliable does not necessarily mean it is effaced. The cervix can soften before it thins and shortens.

Choice C is wrong because cervix is dilated and open indicates cervical dilation, which is the opening of the cervix. Cervical dilation is measured in centimeters, from 0 cm (closed) to 10 cm (fully dilated).

Cervical dilation and effacement are related, but not the same.

Choice D is wrong because cervix is posterior and high indicates the position of the cervix in relation to the vagina. The cervix can move from posterior (back) to anterior (front) and from high to low as labor progresses.

The position of the cervix does not indicate effacement.

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Correct Answer is B

Explanation

Instruct the client to empty her bladder.This is because a full bladder can interfere with the insertion of the needle and increase the risk of injury to the bladder or the uterus.Emptying the bladder also reduces discomfort during the procedure.

Choice A is wrong because administering tocolytic medication to stop contractions is not necessary before amniocentesis.Tocolytic medication can have side effects and should only be used when there is a clear indication of preterm labor.

Choice C is wrong because obtaining informed consent from the client is not a nursing action, but a medical one.The nurse can assist in providing information and answering questions, but the final consent should be obtained by the doctor who will perform the procedure.

Choice D is wrong because monitoring fetal heart rate and activity is not a specific action before amniocentesis, but a routine part of prenatal care.Fetal heart rate and activity can be affected by many factors, such as maternal position, fetal sleep cycle, or maternal blood sugar level.

Monitoring them before amniocentesis does not provide any useful information for the procedure.

A. Administer IV fluids B. Obtain a urine specimen C. Assess fetal heart rate D. Insert an indwelling urinary catheter

Correct Answer is C

Explanation

This is because assessing fetal heart rate is the most important action to take first when a client has prelabor rupture of membranes (PROM) at 34 weeks of gestation and oligohydramnios.Fetal heart rate can indicate fetal well-being, distress, or infection.Oligohydramnios can increase the risk of umbilical cord compression and fetal hypoxia.

Choice A is wrong because administering IV fluids is not the first priority in this situation.IV fluids may be given to prevent dehydration, enhance uterine blood flow, or augment labor, but they are not as urgent as assessing fetal heart rate.

Choice B is wrong because obtaining a urine specimen is not the first priority in this situation.A urine specimen may be obtained to check for infection, proteinuria, or glucose levels, but they are not as urgent as assessing fetal heart rate.

Choice D is wrong because inserting an indwelling urinary catheter is not the first priority in this situation.An indwelling urinary catheter may be inserted to monitor fluid balance, prevent bladder distension, or reduce the risk of infection, but they are not as urgent as assessing fetal heart rate.

Normal ranges for fetal heart rate are 110 to 160 beats per minute.Oligohydramnios is defined as an amniotic fluid index of less than 5 cm.

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A nurse is performing a digital examination on a client who is at 34 weeks of gestation and has pre-term labor. Which of the following findings indicates cervical effacement?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform an amniocentesis on a client who is at 27 weeks of gestation and has pre-term labor. Which of the following actions should the nurse take before the procedure?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse is performing a digital examination on a client who is at 34 weeks of gestation and has pre-term labor.

Which of the following findings indicates cervical effacement?