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. Massaging the client's back – Correct; gate control theory states that non-painful stimuli (e.g., massage, heat, cold) can block pain signals from reaching the brain.

B. Administering prescribed analgesic medication – Incorrect; this is pharmacologic pain relief, not part of gate control theory.

C. Turning the client onto her left side – Incorrect; this improves circulation but does not block pain signals.

D. Encouraging the client to rest between contractions – Incorrect; rest is important but does not directly affect pain perception.

A. "Epidurals are best because they provide complete pain relief." B. "Most women need IV pain medications at some point during labor." C. "It is best to learn about the different types of pain relief available, as every woman experiences labor pain differently." D. "There is no one best way. However, natural childbirth is best for the baby."

Correct Answer is C

Explanation

A. "Epidurals are best because they provide complete pain relief." – Incorrect; while epidurals provide significant pain relief, they may not be the best option for every client.
B. "Most women need IV pain medications at some point during labor." – Incorrect; pain management is individualized, and not all women require IV pain medication.
C. "It is best to learn about the different types of pain relief available, as every woman experiences labor pain differently." – Correct; pain relief options should be tailored to the individual's preferences and medical condition.
D. "There is no one best way. However, natural childbirth is best for the baby." – Incorrect; while natural childbirth is an option, it is not necessarily the best choice for everyone.

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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

A nurse is assisting with the care of a client who is in latent labor. Which of the following nursing actions reflects the application of the gate control theory of pain?

Correct Answer is A

Explanation

A woman asks the nurse during a prenatal office visit, "What pain relief method is best during labor?" What answer by the nurse best answers the question?

Correct Answer is C

Explanation

A medication is prescribed based on a pediatric patient's weight. What should the nurse consider when calculating the dosage?

A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

A practical nurse is gathering data on a laboring client's perception of pain. Which of the following should be included? (Select All that Apply.)

A nurse is caring for a client who is at 12 weeks of gestation during an initial prenatal visit. The client asks, "What is a normal fetal heart rate?" Which of the following ranges should the nurse provide?

A client is 39 weeks in labor. This is her third pregnancy. She reports an early miscarriage at 8 weeks and a stillborn at 36 weeks. What is her GTPAL?

The role of the practical nurse during labor includes all EXCEPT (Select All that Apply.)

A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?

A nurse assisting in the care of a client, places the tocodynamometer (TOCO) transducer on a client's fundus and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?