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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Blood pressure of 150/90 mmHg.This is because terbutaline can causeelevated blood pressureas a side effect.
The nurse should report this finding to the provider as it may indicate hypertension or a hypertensive crisis.
Choice A is wrong because a heart rate of 110/min is not abnormal for a person who has received terbutaline.Terbutaline can causefast or pounding heartbeatsas a common side effect.
Choice C is wrong because a blood glucose of 90 mg/dL is within the normal range of 70-130 mg/dL before meals.Terbutaline can causetransient hyperglycemia(high blood sugar) as a serious side effect, but this is not the case here.
Choice D is wrong because a temperature of 37°C (98.6°F) is normal for a human being.Terbutaline does not cause fever or hypothermia as a side effect.
Correct Answer is A
Explanation
Leukocoria (white pupils) is a symptom of retinopathy of prematurity (ROP), an eye disease that can happen in premature babies.ROP happens when abnormal blood vessels grow on the retina, the light-sensitive layer of tissue in the back of the eye.
Choice B is wrong because strabismus (crossed eyes) is not a symptom of ROP, but a possible complication that can occur later in life.
Choice C is wrong because nystagmus (involuntary eye movements) is not a symptom of ROP, but another possible complication that can occur later in life.
Choice D is wrong because it includes choices B and C, which are incorrect.
Normal ranges for gestational age and birth weight are 38 to 42 weeks and 5.5 to 10 pounds, respectively.Babies born before 31 weeks or weighing less than 3 pounds are at risk for ROP.
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