The nurse assesses a laboring client's cervix and states it is 6 cm dilated and 70% effaced.
The client asks what it means to be effaced. Which descriptions will the nurse include when responding to the client? Select all that apply.
It becomes thinner
It becomes shorter
It becomes engaged
It becomes wider
Correct Answer : A,B
A. Effacement refers to the thinning of the cervix, making it easier for the cervix to dilate during labor.
B. Effacement also involves the shortening of the cervix, contributing to the progressive dilation during labor.
C. Engagement refers to the descent of the fetal head into the pelvic inlet, not a part of effacement.
D. Effacement does not involve the cervix becoming wider; dilation refers to the opening of the cervix.
E. Effacement does not involve the cervix becoming lower; descent of the presenting part is associated with engagement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Late decelerations typically start after the contraction has reached its peak and return to baseline after the contraction ends, not during the contraction.
B. Early decelerations coincide with the contraction and return to baseline by the end of the contraction. They are typically considered benign and related to head compression.
C. Accelerations are brief increases in the FHR above the baseline and are usually associated with fetal movement.
D. Variable decelerations are abrupt decreases in the FHR, often unrelated to contractions, and have an erratic pattern.
Correct Answer is B
Explanation
A. Placing the client on her left side is important for optimizing fetal oxygenation but is not the first action when there is a report of a gush of fluid.
B. Notifying the registered nurse (RN) immediately is the first action to ensure prompt assessment and appropriate interventions for possible ruptured membranes.
C. Documenting the time and color of the fluid is important, but immediate notification of the RN takes precedence.
D. Checking fetal heart tones is important but should be done in conjunction with notifying the RN to assess the overall situation and determine the appropriate course of action.
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