INTRAPARTUM CARE, IMMEDIATE NEWBORN
CARE NCLEX QUESTIONS WITH CORRECT
ANSWERS
A nurse is caring for a client in her third stage of labor. Which findings would
the nurse assess as indicating placental separation? Select all that apply.
A) fresh gushing of blood from the vagina
B) a relaxed and distended uterus
C) umbilical cord descending lower down
D) renewed bearing down efforts by client
E) falling downward of uterus in the abdomen --ANSWER--A) fresh gushing of
blood from the vagina
C) umbilical cord descending lower down
D) renewed bearing down efforts by client
The signs of placental separation include a fresh gush of blood from the vagina,
lengthening of the umbilical cord, and renewed bearing-down efforts by the
client. When the client is in her third stage of labor, these indicate placental
separation. A rising upwards of the uterus and a well-contracted globular uterus
are the other signs of placental separation. Falling downward of the uterus in the
abdomen and a relaxed uterus are the signs of uterine atony.
Page | 1
,A nurse is caring for a pregnant client at her 34-week checkup. The client has
chosen the Lamaze method for her birthing plan but states that her partner does
not agree. The client says she will just change her plan. Which response by the
nurse would be appropriate to support the female client?
A) "Have you and your partner discussed what his / her role will be in the
birth?"
B) "Just wait until the birth; your partner's mind could change."
C) "Preparing for the birth works for some clients, but not for all."
D) "Maybe you should choose a different support person." --ANSWER--A)
"Have you and your partner discussed what his / her role will be in the birth?"
The nurse should explain to the client the different roles the partner can take in
the birth process. The nurse should encourage the client to discuss both her
feelings and her partner's feelings to better understand the partner's disapproval
of Lamaze. This could help improve family communication. The other three
answers are not therapeutic because they ignore the client's concern and do not
help to prepare the client.
A pregnant woman, multipara, has been in labor for several hours. She cries out
that her contractions are getting harder and that she cannot do this. The client is
really irritable, nauseated, annoyed, and fearful of being left alone. Considering
the client's behavior, the nurse would expect the cervix to be dilated how many
centimeters?
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,A) 3 to 5
B) 0 to 2
C) 5 to 6
D) 8 to 10 --ANSWER--D) 8 to 10
The reaction of the client is indicative of entering or being in the transition
phase of labor, stage 1. The dilation would be 8-10 cm. Before that, when
dilation is 0 to 7 cm, the client has an easier time using positive coping skills.
The first stage of labor is often a time of introspection. In light of this, which
information would guide the nurse's planning of nursing care?
A) A woman should be left entirely alone during this period.
B) A woman will rarely speak or laugh during this period.
C) A woman may spend time thinking about what is happening to her.
D) No nursing care is needed to be done during this time. --ANSWER--C) A
woman may spend time thinking about what is happening to her.
Women need a support person with them during all stages of labor.
A nurse is conducting an in-service program for staff nurses working in the
labor and birth unit. The nurse is discussing ways to promote a positive birth
Page | 3
, outcome for the woman in labor. The nurse determines that additional teaching
is necessary when the group identifies which measure?
A) allowing the woman time to be alone
B) promoting the woman's feelings of control
C) providing clear information about procedures
D) encouraging the woman to use relaxation techniques --ANSWER--A)
allowing the woman time to be alone
Positive support, not being alone, promotes a positive birth experience. Being
alone can increase anxiety and fear, decreasing the woman's ability to cope.
Feelings of control promote self-confidence and self-esteem, which in turn help
the woman to cope with the challenges of labor. Information about procedures
reduces anxiety about the unknown and fosters cooperation and self-confidence
in her abilities to deal with labor. Catecholamines are secreted in response to
anxiety and fear and can inhibit uterine blood flow and placental perfusion.
Relaxation techniques can help to reduce anxiety and fear, in turn decreasing
the secretion of catecholamines and ultimately improving the woman's ability to
cope with labor.
Assessment reveals that the fetus of a client in labor is in the vertex
presentation. The nurse determines that which part is presenting?
A) shoulders
B) buttocks
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CARE NCLEX QUESTIONS WITH CORRECT
ANSWERS
A nurse is caring for a client in her third stage of labor. Which findings would
the nurse assess as indicating placental separation? Select all that apply.
A) fresh gushing of blood from the vagina
B) a relaxed and distended uterus
C) umbilical cord descending lower down
D) renewed bearing down efforts by client
E) falling downward of uterus in the abdomen --ANSWER--A) fresh gushing of
blood from the vagina
C) umbilical cord descending lower down
D) renewed bearing down efforts by client
The signs of placental separation include a fresh gush of blood from the vagina,
lengthening of the umbilical cord, and renewed bearing-down efforts by the
client. When the client is in her third stage of labor, these indicate placental
separation. A rising upwards of the uterus and a well-contracted globular uterus
are the other signs of placental separation. Falling downward of the uterus in the
abdomen and a relaxed uterus are the signs of uterine atony.
Page | 1
,A nurse is caring for a pregnant client at her 34-week checkup. The client has
chosen the Lamaze method for her birthing plan but states that her partner does
not agree. The client says she will just change her plan. Which response by the
nurse would be appropriate to support the female client?
A) "Have you and your partner discussed what his / her role will be in the
birth?"
B) "Just wait until the birth; your partner's mind could change."
C) "Preparing for the birth works for some clients, but not for all."
D) "Maybe you should choose a different support person." --ANSWER--A)
"Have you and your partner discussed what his / her role will be in the birth?"
The nurse should explain to the client the different roles the partner can take in
the birth process. The nurse should encourage the client to discuss both her
feelings and her partner's feelings to better understand the partner's disapproval
of Lamaze. This could help improve family communication. The other three
answers are not therapeutic because they ignore the client's concern and do not
help to prepare the client.
A pregnant woman, multipara, has been in labor for several hours. She cries out
that her contractions are getting harder and that she cannot do this. The client is
really irritable, nauseated, annoyed, and fearful of being left alone. Considering
the client's behavior, the nurse would expect the cervix to be dilated how many
centimeters?
Page | 2
,A) 3 to 5
B) 0 to 2
C) 5 to 6
D) 8 to 10 --ANSWER--D) 8 to 10
The reaction of the client is indicative of entering or being in the transition
phase of labor, stage 1. The dilation would be 8-10 cm. Before that, when
dilation is 0 to 7 cm, the client has an easier time using positive coping skills.
The first stage of labor is often a time of introspection. In light of this, which
information would guide the nurse's planning of nursing care?
A) A woman should be left entirely alone during this period.
B) A woman will rarely speak or laugh during this period.
C) A woman may spend time thinking about what is happening to her.
D) No nursing care is needed to be done during this time. --ANSWER--C) A
woman may spend time thinking about what is happening to her.
Women need a support person with them during all stages of labor.
A nurse is conducting an in-service program for staff nurses working in the
labor and birth unit. The nurse is discussing ways to promote a positive birth
Page | 3
, outcome for the woman in labor. The nurse determines that additional teaching
is necessary when the group identifies which measure?
A) allowing the woman time to be alone
B) promoting the woman's feelings of control
C) providing clear information about procedures
D) encouraging the woman to use relaxation techniques --ANSWER--A)
allowing the woman time to be alone
Positive support, not being alone, promotes a positive birth experience. Being
alone can increase anxiety and fear, decreasing the woman's ability to cope.
Feelings of control promote self-confidence and self-esteem, which in turn help
the woman to cope with the challenges of labor. Information about procedures
reduces anxiety about the unknown and fosters cooperation and self-confidence
in her abilities to deal with labor. Catecholamines are secreted in response to
anxiety and fear and can inhibit uterine blood flow and placental perfusion.
Relaxation techniques can help to reduce anxiety and fear, in turn decreasing
the secretion of catecholamines and ultimately improving the woman's ability to
cope with labor.
Assessment reveals that the fetus of a client in labor is in the vertex
presentation. The nurse determines that which part is presenting?
A) shoulders
B) buttocks
Page | 4
