NR 327 Maternal-Child Nursing: Week 3 - Intrapartum Care 2026
|Chamberlain College
1. A nurse is assessing a client in the active phase of the first stage of labor.
Which of the following findings should the nurse expect?
A. Cervical dilation of 2 cm
B. Expulsion of the placenta
C. Strong urge to push
D. Cervical dilation of 6 cm
Answer: D
Rationale: The active phase of labor is characterized by cervical dilation ranging from 4 to
7 cm (or 6 cm according to newer ACOG guidelines). Dilation of 2 cm is the latent phase,
and the urge to push occurs in the second stage.
2. A client in labor is receiving an epidural block. Which of the following is the
most important nursing intervention following the start of the infusion?
A. Encourage the client to walk around the room
B. Assess for bladder distention every 2 hours
C. Monitor maternal blood pressure every 5 minutes
D. Instruct the client to remain in a supine position
Answer: C
Rationale: The most common side effect of epidural anesthesia is maternal hypotension.
Continuous monitoring of blood pressure is critical to ensure adequate placental perfusion.
,3. The nurse observes late decelerations on the fetal heart rate (FHR) monitor.
Which of the following actions should the nurse take first?
A. Increase the oxytocin infusion rate
B. Notify the provider immediately
C. Perform a vaginal examination
D. Place the client in a side-lying position
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority action is to
improve placental blood flow by positioning the client on their side, followed by oxygen
and fluid bolus.
4. A nurse is reviewing the FHR monitor strip and notes a baseline of 140/min
with moderate variability and no decelerations. How should the nurse
categorize this strip?
A. Abnormal
B. Category II
C. Category III
D. Category I
Answer: D
Rationale: Category I FHR patterns are normal, with a baseline of 110-160/min, moderate
variability, and no late or variable decelerations.
5. Which of the following measurements indicates that the fetus is at ‘station
0’?
A. The fetal head is 1 cm above the ischial spines
B. The fetal head is crowning at the vaginal opening
C. The fetal head is 1 cm below the ischial spines
D. The fetal head is level with the ischial spines
Answer: D
, Rationale: Station 0 indicates that the presenting part is at the level of the maternal ischial
spines, which signifies engagement.
6. A nurse is caring for a client in the transition phase of labor. Which behavior
should the nurse anticipate?
A. Excitement and talking about the baby
B. Quietness and focusing inward
C. Irritability and loss of control
D. Sleeping between contractions
Answer: C
Rationale: The transition phase (8-10 cm) is often the most intense, and clients frequently
exhibit irritability, nausea, and a feeling of being overwhelmed.
7. What is the primary purpose of performing Leopold’s maneuvers?
A. To estimate the amount of amniotic fluid
B. To determine the fetal position and presentation
C. To assess the intensity of uterine contractions
D. To identify the location of the placenta
Answer: B
Rationale: Leopold’s maneuvers are a series of four abdominal palpations used to
determine fetal lie, presentation, and position to locate the FHR.
8. A nurse is assessing a client who has a suspected rupture of membranes.
Which finding confirms the membranes have ruptured?
A. Nitrazine paper turns yellow
B. Negative ferning test
C. Presence of lochia rubra
D. Nitrazine paper turns blue-green
Answer: D
|Chamberlain College
1. A nurse is assessing a client in the active phase of the first stage of labor.
Which of the following findings should the nurse expect?
A. Cervical dilation of 2 cm
B. Expulsion of the placenta
C. Strong urge to push
D. Cervical dilation of 6 cm
Answer: D
Rationale: The active phase of labor is characterized by cervical dilation ranging from 4 to
7 cm (or 6 cm according to newer ACOG guidelines). Dilation of 2 cm is the latent phase,
and the urge to push occurs in the second stage.
2. A client in labor is receiving an epidural block. Which of the following is the
most important nursing intervention following the start of the infusion?
A. Encourage the client to walk around the room
B. Assess for bladder distention every 2 hours
C. Monitor maternal blood pressure every 5 minutes
D. Instruct the client to remain in a supine position
Answer: C
Rationale: The most common side effect of epidural anesthesia is maternal hypotension.
Continuous monitoring of blood pressure is critical to ensure adequate placental perfusion.
,3. The nurse observes late decelerations on the fetal heart rate (FHR) monitor.
Which of the following actions should the nurse take first?
A. Increase the oxytocin infusion rate
B. Notify the provider immediately
C. Perform a vaginal examination
D. Place the client in a side-lying position
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority action is to
improve placental blood flow by positioning the client on their side, followed by oxygen
and fluid bolus.
4. A nurse is reviewing the FHR monitor strip and notes a baseline of 140/min
with moderate variability and no decelerations. How should the nurse
categorize this strip?
A. Abnormal
B. Category II
C. Category III
D. Category I
Answer: D
Rationale: Category I FHR patterns are normal, with a baseline of 110-160/min, moderate
variability, and no late or variable decelerations.
5. Which of the following measurements indicates that the fetus is at ‘station
0’?
A. The fetal head is 1 cm above the ischial spines
B. The fetal head is crowning at the vaginal opening
C. The fetal head is 1 cm below the ischial spines
D. The fetal head is level with the ischial spines
Answer: D
, Rationale: Station 0 indicates that the presenting part is at the level of the maternal ischial
spines, which signifies engagement.
6. A nurse is caring for a client in the transition phase of labor. Which behavior
should the nurse anticipate?
A. Excitement and talking about the baby
B. Quietness and focusing inward
C. Irritability and loss of control
D. Sleeping between contractions
Answer: C
Rationale: The transition phase (8-10 cm) is often the most intense, and clients frequently
exhibit irritability, nausea, and a feeling of being overwhelmed.
7. What is the primary purpose of performing Leopold’s maneuvers?
A. To estimate the amount of amniotic fluid
B. To determine the fetal position and presentation
C. To assess the intensity of uterine contractions
D. To identify the location of the placenta
Answer: B
Rationale: Leopold’s maneuvers are a series of four abdominal palpations used to
determine fetal lie, presentation, and position to locate the FHR.
8. A nurse is assessing a client who has a suspected rupture of membranes.
Which finding confirms the membranes have ruptured?
A. Nitrazine paper turns yellow
B. Negative ferning test
C. Presence of lochia rubra
D. Nitrazine paper turns blue-green
Answer: D
