Study Guide
Which clinical situation would the nurse recall is associated with fetal compromise?
SELECT ALL THAT APPLY
A) A maternal temperature of 100.8F
B) Amniotic fluid with small bits of vernix
C) Fetal heart rate of 165 beats per minute over 10 minutes
D) Incomplete uterine relaxation between contractions
E) Six uterine contractions 60 seconds in duration over 10 minutes - correct answer ✔✔A) A
maternal temperature of 100.8F
C) Fetal heart rate of 165 beats per minute over 10 minutes
D) Incomplete uterine relaxation between contractions
E) Six uterine contractions 60 seconds in duration over 10 minutes
Which clinical finding would the nurse anticipate for a patient in the fourth stage of labor with a
full bladder?
SELECT ALL THAT APPLY
A) Soft uterus
B) Intense perineal pain
C) Elevated uterine fundus
D) Displacement of the uterus
,E) Pain unrelieved by analgesics - correct answer ✔✔A) Soft uterus
C) Elevated uterine fundus
D) Displacement of the uterus
Which maternal position would the nurse encourage for a laboring patient who is experiencing
back pain with her contractions?
A) Standing
B) Side-lying
C) Sitting upright
D) Hands and knees - correct answer ✔✔D) Hands and knees
Which rationale describes the purpose of performing the first Leopold maneuver?
A) Identify fetal presentation
B) Determine location of the heart
C) Determine which side fetal back is facing
D) Understand engagement of presenting part - correct answer ✔✔A) Identify fetal
presentation
Which initial assessment would the nurse perform for a patient who was admitted to the unit at
36 weeks of gestation and states that she has a severe headache, sees flashes of lights, and
thinks her amniotic fluid is leaking?
A) Fetal heart rate
,B) Vaginal pH testing
C) Maternal vital signs
D) Leopold maneuver - correct answer ✔✔C) Maternal vital signs
During which stage of labor would the nurse anticipate the mother to exhibit excitement and
often cry?
A) First
B) Second
C) Third
D) Fourth - correct answer ✔✔C) Third
In which stage of labor would the nurse expect the placenta to be expelled?
A) First
B) Second
C) Third
D) Fourth - correct answer ✔✔C) Third
A newly admitted patient states, "I do not want any pain medication at all during labor." In
which way would the nurse respond based on the additional assessment data?
A) "If you change your mind, let me know."
B) "We can discuss several options to promote comfort."
C) "I am concerned your pain level is quite high in the early stage of labor."
D) "I can review some medication options in case you change your mind." - correct answer
✔✔B) "We can discuss several options to promote comfort."
, Which information would the nurse provide when teaching a patient how to count the
frequency of contractions?
A) The time at the beginning of one contraction to the end of the contraction
B) The time at the end of one contraction to the beginning of the next contraction
C) The time at the beginning of one contraction to the end of the next contraction
D) The time at the beginning of one contraction to the beginning of the next contraction -
correct answer ✔✔D) The time at the beginning of one contraction to the beginning of the next
contraction
The nurse would tell a primigravida patient that which is the definitive sign indicating that labor
has begun?
A) Lightening
B) Rupture of membranes
C) Passage of the mucous plug (operculum)
D) Progressive uterine contractions with cervical change - correct answer ✔✔D) Progressive
uterine contractions with cervical change
Which clinical assessment finding would the nurse expect for a patient suspected of being a
victim of intimate partner violence (IPV)?
A) Labile affect
B) Overnutrition
C) Chronic diarrhea
D) Abdominal pain - correct answer ✔✔D) Abdominal pain