mom baby exam 1 questions and
complete solutions 2025/2026
1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the
2nd stage of labor when which of the following assessments is noted?
A.The client begins to expel clear vaginal fluid
B.The contractions are regular
C.The membranes have ruptured
D.The cervix is dilated completely - CORRECT ANSWER ✔✔1.4. The second stage of labor begins
when the cervix is dilated completely and ends with the birth of the neonate.
A nurse in the labor room is caring for a client in the active phases of labor. The nurse is
assessing the fetal patterns and notes a late deceleration on the monitor strip. The most
appropriate nursing action is to:
1.Place the mother in the supine position
2.Document the findings and continue to monitor the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV infusion - CORRECT ANSWER ✔✔3. Late decelerations are due
to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus
during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The
supine position is avoided because it decreases uterine blood flow to the fetus. The client
should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava.
An intravenous pitocin infusion is discontinued when a late deceleration is noted.
A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which
assessment finding would indicate a need to contact the physician?
1.Fetal heart rate of 180 beats per minute
, 2.White blood cell count of 12,000
3.Maternal pulse rate of 85 beats per minute
4.Hemoglobin of 11.0 g/dL - CORRECT ANSWER ✔✔1. A normal fetal heart rate is 120-160 beats
per minute. A count of 180 beats per minute could indicate fetal distress and would warrant
physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a
result of the hemodilution caused by an increase in plasma volume during pregnancy.
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine
contractions. Which assessment finding would indicate to the nurse that the infusion needs to
be discontinued?
1.Three contractions occurring within a 10-minute period
2.A fetal heart rate of 90 beats per minute
3.Adequate resting tone of the uterus palpated between contractions
4.Increased urinary output - CORRECT ANSWER ✔✔2. A normal fetal heart rate is 120-160 BPM.
Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue
to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-
minute period.
A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of
Pitocin. The nurse ensures that which of the following is implemented before initiating the
infusion?
1.Placing the client on complete bed rest
2.Continuous electronic fetal monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the client's bedside - CORRECT ANSWER ✔✔2. Continuous electronic
fetal monitoring should be implemented during an IV infusion of Pitocin.
complete solutions 2025/2026
1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the
2nd stage of labor when which of the following assessments is noted?
A.The client begins to expel clear vaginal fluid
B.The contractions are regular
C.The membranes have ruptured
D.The cervix is dilated completely - CORRECT ANSWER ✔✔1.4. The second stage of labor begins
when the cervix is dilated completely and ends with the birth of the neonate.
A nurse in the labor room is caring for a client in the active phases of labor. The nurse is
assessing the fetal patterns and notes a late deceleration on the monitor strip. The most
appropriate nursing action is to:
1.Place the mother in the supine position
2.Document the findings and continue to monitor the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV infusion - CORRECT ANSWER ✔✔3. Late decelerations are due
to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus
during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The
supine position is avoided because it decreases uterine blood flow to the fetus. The client
should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava.
An intravenous pitocin infusion is discontinued when a late deceleration is noted.
A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which
assessment finding would indicate a need to contact the physician?
1.Fetal heart rate of 180 beats per minute
, 2.White blood cell count of 12,000
3.Maternal pulse rate of 85 beats per minute
4.Hemoglobin of 11.0 g/dL - CORRECT ANSWER ✔✔1. A normal fetal heart rate is 120-160 beats
per minute. A count of 180 beats per minute could indicate fetal distress and would warrant
physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a
result of the hemodilution caused by an increase in plasma volume during pregnancy.
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine
contractions. Which assessment finding would indicate to the nurse that the infusion needs to
be discontinued?
1.Three contractions occurring within a 10-minute period
2.A fetal heart rate of 90 beats per minute
3.Adequate resting tone of the uterus palpated between contractions
4.Increased urinary output - CORRECT ANSWER ✔✔2. A normal fetal heart rate is 120-160 BPM.
Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue
to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-
minute period.
A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of
Pitocin. The nurse ensures that which of the following is implemented before initiating the
infusion?
1.Placing the client on complete bed rest
2.Continuous electronic fetal monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the client's bedside - CORRECT ANSWER ✔✔2. Continuous electronic
fetal monitoring should be implemented during an IV infusion of Pitocin.
