NURS 203 | NURS 203 Maternity Exam 3 Version 1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient is in the transition phase of the first stage of labor. Which cervical dilation
measurement should the nurse expect to find?
A. 1 to 3 cm
B. 4 to 7 cm
C. Full effacement with no dilation
D. 8 to 10 cm
Correct Answer: D
Expert Explanation: The first stage of labor is divided into the latent, active, and
transition phases. Transition is the final part of this stage and involves dilation from
8 to 10 centimeters. During this time, contractions are intense and occur every 2 to
3 minutes. Patients often experience significant pressure and a desire to push. This
phase is typically the shortest but most difficult part of labor for the mother.
2. The nurse notes variable decelerations on the fetal heart rate monitor. What is the
primary cause of this finding?
A. Head compression
,B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Fetal sleep cycle
Correct Answer: B
Expert Explanation: Variable decelerations are characterized by an abrupt
decrease in fetal heart rate below the baseline. These decelerations are most
commonly caused by compression of the umbilical cord. The shape of the
deceleration often looks like a U, V, or W on the tracing. Changing the mother’s
position is the first priority to relieve the pressure on the cord. If left unmanaged,
persistent variables can lead to fetal hypoxia.
3. Which nursing intervention is a priority immediately before the administration of an
epidural block?
A. Assessing maternal deep tendon reflexes
B. Performing a sterile vaginal exam
C. Instructing the patient to lie flat on her back
D. Administering an IV fluid bolus
Correct Answer: D
,Expert Explanation: Epidural anesthesia often causes maternal hypotension due to
the blockade of sympathetic nerves. To mitigate this risk, a rapid infusion of 500 to
1000 mL of IV fluids is standard protocol. This bolus helps maintain cardiac output
and placental perfusion when vasodilation occurs. Blood pressure must be
monitored frequently after the procedure to detect any sudden drops. Preventing
hypotension is essential for both maternal safety and fetal well-being.
4. A nurse is assessing a patient and notes the fetal presenting part is at ‘0 station.’
What does this indicate?
A. The fetus is floating above the pelvic inlet
B. The fetus is delivered through the vaginal opening
C. The fetus is in a breech presentation
D. The presenting part is at the level of the ischial spines
Correct Answer: D
Expert Explanation: Station is a measurement of the progress of descent in
centimeters. A station of 0 indicates that the fetal presenting part has reached the
level of the ischial spines. This point is also referred to as engagement in the pelvic
canal. Negative numbers indicate the fetus is still above the ischial spines. Positive
numbers indicate the fetus is moving toward the vaginal opening for delivery.
, 5. Which of the following is a characteristic sign of the second stage of labor?
A. Dilation of the cervix to 5 cm
B. Expulsion of the placenta
C. The mother feels an involuntary urge to push
D. The onset of regular uterine contractions
Correct Answer: C
Expert Explanation: The second stage of labor begins when the cervix is fully
dilated to 10 cm. This stage ends with the actual birth of the newborn baby. During
this time, the mother feels a strong, involuntary Ferguson reflex or urge to push.
Nursing care focuses on coaching effective pushing and monitoring the fetal
response to descent. This stage can last from a few minutes to several hours
depending on parity.
6. While monitoring a fetal heart rate, the nurse observes late decelerations. What is
the most likely underlying cause?
A. Maternal position change to the side
B. Fetal head compression during contractions
C. Uteroplacental insufficiency
D. Normal fetal activity and movement
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient is in the transition phase of the first stage of labor. Which cervical dilation
measurement should the nurse expect to find?
A. 1 to 3 cm
B. 4 to 7 cm
C. Full effacement with no dilation
D. 8 to 10 cm
Correct Answer: D
Expert Explanation: The first stage of labor is divided into the latent, active, and
transition phases. Transition is the final part of this stage and involves dilation from
8 to 10 centimeters. During this time, contractions are intense and occur every 2 to
3 minutes. Patients often experience significant pressure and a desire to push. This
phase is typically the shortest but most difficult part of labor for the mother.
2. The nurse notes variable decelerations on the fetal heart rate monitor. What is the
primary cause of this finding?
A. Head compression
,B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Fetal sleep cycle
Correct Answer: B
Expert Explanation: Variable decelerations are characterized by an abrupt
decrease in fetal heart rate below the baseline. These decelerations are most
commonly caused by compression of the umbilical cord. The shape of the
deceleration often looks like a U, V, or W on the tracing. Changing the mother’s
position is the first priority to relieve the pressure on the cord. If left unmanaged,
persistent variables can lead to fetal hypoxia.
3. Which nursing intervention is a priority immediately before the administration of an
epidural block?
A. Assessing maternal deep tendon reflexes
B. Performing a sterile vaginal exam
C. Instructing the patient to lie flat on her back
D. Administering an IV fluid bolus
Correct Answer: D
,Expert Explanation: Epidural anesthesia often causes maternal hypotension due to
the blockade of sympathetic nerves. To mitigate this risk, a rapid infusion of 500 to
1000 mL of IV fluids is standard protocol. This bolus helps maintain cardiac output
and placental perfusion when vasodilation occurs. Blood pressure must be
monitored frequently after the procedure to detect any sudden drops. Preventing
hypotension is essential for both maternal safety and fetal well-being.
4. A nurse is assessing a patient and notes the fetal presenting part is at ‘0 station.’
What does this indicate?
A. The fetus is floating above the pelvic inlet
B. The fetus is delivered through the vaginal opening
C. The fetus is in a breech presentation
D. The presenting part is at the level of the ischial spines
Correct Answer: D
Expert Explanation: Station is a measurement of the progress of descent in
centimeters. A station of 0 indicates that the fetal presenting part has reached the
level of the ischial spines. This point is also referred to as engagement in the pelvic
canal. Negative numbers indicate the fetus is still above the ischial spines. Positive
numbers indicate the fetus is moving toward the vaginal opening for delivery.
, 5. Which of the following is a characteristic sign of the second stage of labor?
A. Dilation of the cervix to 5 cm
B. Expulsion of the placenta
C. The mother feels an involuntary urge to push
D. The onset of regular uterine contractions
Correct Answer: C
Expert Explanation: The second stage of labor begins when the cervix is fully
dilated to 10 cm. This stage ends with the actual birth of the newborn baby. During
this time, the mother feels a strong, involuntary Ferguson reflex or urge to push.
Nursing care focuses on coaching effective pushing and monitoring the fetal
response to descent. This stage can last from a few minutes to several hours
depending on parity.
6. While monitoring a fetal heart rate, the nurse observes late decelerations. What is
the most likely underlying cause?
A. Maternal position change to the side
B. Fetal head compression during contractions
C. Uteroplacental insufficiency
D. Normal fetal activity and movement
