NCLEX 3000 Maternal-Intrapartum Exam Questions
With Complete Answers
(Select all that apply) A nurse is assigned to assist with the admission of a client who is
in labor. Which of the following actions are appropriate? - ANSWER (1) Asking about the
estimated date of delivery (EDD), (3) Taking maternal and fetal vital signs, (6) Asking
about the amount of time between contractions
Which of the following is the most serious adverse effect associated with oxytocin
(Pitocin) administration during labor? - ANSWER Tetanic contractions
Which intervention should be included in the safety plan for the maternal-infant unit? -
ANSWER Making sure that the spouse or significant other wears an identification band
When caring for a client in the first stage of labor, the nurse documents cervical dilation
of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2
minutes. Based on these findings, the nurse should recognize that the client is in which
phase of labor? - ANSWER Transitional phase
After admission to the labor and delivery area, a client undergoes routine tests,
including a complete blood count, urinalysis, Venereal Disease Research Laboratory
test, and gonorrhea culture. The gonorrhea culture is positive, although the client
doesn't have signs and symptoms of this disease. What is the significance of this
finding? - ANSWER Maternal gonorrhea may cause an eye infection in the neonate.
A client is recovering in the labor and delivery area after delivering a 6-lb, 3-oz boy. On
assessment, the nurse finds that the client's fundus is firm and located two
fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her
perineal pad reveals a steady trickle of blood. What is the probable cause of these
assessment findings? - ANSWER A vaginal laceration
A client in the early stages of active labor wants to get out of bed and walk around the
room. Which action by the nurse is best? - ANSWER Assisting the client to ambulate in
the room
,When caring for a client who's a primigravida, the nurse would expect the second stage
of labor to last how long? - ANSWER Approximately 2 hours
(SELECT ALL THAT APPLY) A client receives an epidural block for pain relief during
labor. Which interventions by the nurse are important when caring for a client with an
epidural block? - ANSWER (1) Make sure oxygen is available., (3) Monitor vital signs
frequently., (5) Monitor fetal heart rate and contractions closely.
A client is in the second stage of labor. During this stage, how frequently should the
nurse assess her uterine contractions? - ANSWER Every 15 minutes
Which of the following physiologic changes during labor makes it necessary for the
nurse to check blood pressure frequently? - ANSWER Alterations in cardiovascular
function affect the fetus.
A primigravid client is admitted to the labor and delivery area, where the nurse
evaluates her. Which data collection finding may indicate the need for cesarean
delivery? - ANSWER Umbilical cord prolapse
Which of the following behaviors would cause the nurse to suspect that a client's labor
is moving quickly and that the physician should be notified? - ANSWER An increased
sense of rectal pressure
For a client who's moving into the active phase of labor, the nurse should include which
of the following as the priority of care? - ANSWER Offer support by reviewing the
short-pant form of breathing.
Late in the first stage of labor, a client receives a spinal block to relieve discomfort. A
short time later, her husband tells the nurse that his wife feels dizzy and is complaining
of numbness around her lips. What do the client's symptoms suggest? - ANSWER
Anesthesia overdose
, The third stage of labor ends: - ANSWER after the birth of the placenta.
A client who's being admitted to labor and delivery has the following data collection
findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart,
lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this
time? - ANSWER Preparing for immediate delivery
A client who tested positive for the human immunodeficiency virus (HIV) is in active
labor. During delivery, blood splashes and contaminates the care area. Which action
should the nurse take? - ANSWER Contact housekeeping and ask them to clean the area
because it has been contaminated by blood-borne pathogens.
(SELECT ALL THAT APPLY) The nurse is assisting in the delivery room. The physician
performs an episiotomy, an incision in the client's perineum to enlarge the vaginal
opening and facilitate delivery. Which interventions should the nurse perform when
caring for the client after this procedure? - ANSWER (1) Check the episiotomy repair
site., (2) Apply ice to the perineum, (4) Administer pain medication, as prescribed., (5)
Explain perineal care to the client when she is able to focus on the instructions.
A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to
push!" An immediate nursing assessment reveals that the head of the fetus is crowning.
After asking another staff member to notify the physician and setting up for delivery,
which nursing intervention is most appropriate? - ANSWER Applying gentle pressure to
the baby's head as it's delivered
The nurse is caring for a client who's in the first stage of labor. What is the shortest but
most difficult part of this stage? - ANSWER Transitional phase
When coaching a client to push, the nurse should encourage her to use which
technique? - ANSWER Pushing when she feels like pushing
A client in labor receives epidural anesthesia. The nurse should assess carefully for
which adverse reaction to the anesthetic agent? - ANSWER Hypotensive crisis
With Complete Answers
(Select all that apply) A nurse is assigned to assist with the admission of a client who is
in labor. Which of the following actions are appropriate? - ANSWER (1) Asking about the
estimated date of delivery (EDD), (3) Taking maternal and fetal vital signs, (6) Asking
about the amount of time between contractions
Which of the following is the most serious adverse effect associated with oxytocin
(Pitocin) administration during labor? - ANSWER Tetanic contractions
Which intervention should be included in the safety plan for the maternal-infant unit? -
ANSWER Making sure that the spouse or significant other wears an identification band
When caring for a client in the first stage of labor, the nurse documents cervical dilation
of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2
minutes. Based on these findings, the nurse should recognize that the client is in which
phase of labor? - ANSWER Transitional phase
After admission to the labor and delivery area, a client undergoes routine tests,
including a complete blood count, urinalysis, Venereal Disease Research Laboratory
test, and gonorrhea culture. The gonorrhea culture is positive, although the client
doesn't have signs and symptoms of this disease. What is the significance of this
finding? - ANSWER Maternal gonorrhea may cause an eye infection in the neonate.
A client is recovering in the labor and delivery area after delivering a 6-lb, 3-oz boy. On
assessment, the nurse finds that the client's fundus is firm and located two
fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her
perineal pad reveals a steady trickle of blood. What is the probable cause of these
assessment findings? - ANSWER A vaginal laceration
A client in the early stages of active labor wants to get out of bed and walk around the
room. Which action by the nurse is best? - ANSWER Assisting the client to ambulate in
the room
,When caring for a client who's a primigravida, the nurse would expect the second stage
of labor to last how long? - ANSWER Approximately 2 hours
(SELECT ALL THAT APPLY) A client receives an epidural block for pain relief during
labor. Which interventions by the nurse are important when caring for a client with an
epidural block? - ANSWER (1) Make sure oxygen is available., (3) Monitor vital signs
frequently., (5) Monitor fetal heart rate and contractions closely.
A client is in the second stage of labor. During this stage, how frequently should the
nurse assess her uterine contractions? - ANSWER Every 15 minutes
Which of the following physiologic changes during labor makes it necessary for the
nurse to check blood pressure frequently? - ANSWER Alterations in cardiovascular
function affect the fetus.
A primigravid client is admitted to the labor and delivery area, where the nurse
evaluates her. Which data collection finding may indicate the need for cesarean
delivery? - ANSWER Umbilical cord prolapse
Which of the following behaviors would cause the nurse to suspect that a client's labor
is moving quickly and that the physician should be notified? - ANSWER An increased
sense of rectal pressure
For a client who's moving into the active phase of labor, the nurse should include which
of the following as the priority of care? - ANSWER Offer support by reviewing the
short-pant form of breathing.
Late in the first stage of labor, a client receives a spinal block to relieve discomfort. A
short time later, her husband tells the nurse that his wife feels dizzy and is complaining
of numbness around her lips. What do the client's symptoms suggest? - ANSWER
Anesthesia overdose
, The third stage of labor ends: - ANSWER after the birth of the placenta.
A client who's being admitted to labor and delivery has the following data collection
findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart,
lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this
time? - ANSWER Preparing for immediate delivery
A client who tested positive for the human immunodeficiency virus (HIV) is in active
labor. During delivery, blood splashes and contaminates the care area. Which action
should the nurse take? - ANSWER Contact housekeeping and ask them to clean the area
because it has been contaminated by blood-borne pathogens.
(SELECT ALL THAT APPLY) The nurse is assisting in the delivery room. The physician
performs an episiotomy, an incision in the client's perineum to enlarge the vaginal
opening and facilitate delivery. Which interventions should the nurse perform when
caring for the client after this procedure? - ANSWER (1) Check the episiotomy repair
site., (2) Apply ice to the perineum, (4) Administer pain medication, as prescribed., (5)
Explain perineal care to the client when she is able to focus on the instructions.
A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to
push!" An immediate nursing assessment reveals that the head of the fetus is crowning.
After asking another staff member to notify the physician and setting up for delivery,
which nursing intervention is most appropriate? - ANSWER Applying gentle pressure to
the baby's head as it's delivered
The nurse is caring for a client who's in the first stage of labor. What is the shortest but
most difficult part of this stage? - ANSWER Transitional phase
When coaching a client to push, the nurse should encourage her to use which
technique? - ANSWER Pushing when she feels like pushing
A client in labor receives epidural anesthesia. The nurse should assess carefully for
which adverse reaction to the anesthetic agent? - ANSWER Hypotensive crisis
