LABOR & DELIVERY SAUNDERS NCLEX QUESTIONS
80QW/EXP, NAXLEX MOST TESTED EXAM QUESTIONS AND
ANSWERS GRADED A+ ASSURED SUCCESS
A client at 32 weeks gestation is hospitalized with severe pregnancy-
induced hypertension (PIH), and magnesium sulfate is prescribed to
control symptoms. Which assessment finding would indicate that
therapeutic drug level has been achieved? Correct Answers Urinary
output of 50 mL per hour.
The nurse is preparing to administer magnesium sulfate to a laboring
client whose blood pressure has risen from 110/60 mmHg to 140/90
mmHg. Which nursing protocol is of the highest priority? Correct
Answers Ensure calcium gluconate is immediately available
The nurse is about to administer phytonadione to a newborn. Which
statement by the parents shows they understand why this medication is
being given? Correct Answers It prevents hemorrhagic disorders.
A patient in early labor is receiving oxytocin and begins to experience
tach systolic or tetanic contractions with variable fetal heart
decelerations. What should the nurse do next? Correct Answers
Discontinue the oxytocin infusion.
A client at 28-weeks gestation whose hemoglobin level is 10.7 g/dL
(107 g/L) and hematocrit is 32.3% (0.323 volume fraction), tells the
nurse that she eats plenty of green vegetables. When the client asks the
nurse how the pregnancy might affect the laboratory findings, which
,information should the nurse provide? Correct Answers Plasma volume
increases, making the blood count appear low.
A 3-year-old male was brought into the emergency room this morning
with a sudden onset of "fast and noisy breathing". According to his
parents, he had sneezing and a runny nose last week but seemed to have
recovered. The child lives with 2 older, school-age siblings, his parents,
and 3 dogs. He was born at 37 weeks' gestation. The parents deny
smoking, but his grandmother cares for him in the afternoons and
smokes outside when she is at the house. He has no significant medical
history. He has received all vaccines except for those due at 3 years.
Upon exam, the child is... Which two items must the nurse ensure are
available before attempting to place the intravenous line? Correct
Answers Manual resuscitation bag, An advanced airway kit
The nurse is reviewing a client's chart.
Click to highlight areas of client history and physical below that
increase the risk for postpartum hemorrhage.
Client was middle-aged and married. She was in labor for 25 hours and
forceps were used to assist with the delivery. She was given an epidural
for anesthesia that was effective. The labor and delivery nurse reported
that the client had a 4th degree laceration, and her pain was currently at
a 4 on a 0 to 10 pain scale. Her vital signs were stable, and she was
catheterized for 500 mL of light-yellow urine just prior to delivery. Her
spouse was at the bedside for delivery. Correct Answers She was in
labor for 25 hours
,-forceps were used to assist with the delivery
-client had a 4th degree laceration
The nurse in a maternity unit is reviewing the clients' records. Which
client would the nurse identify as being at the most risk for developing
disseminated intravascular coagulation(DIC)?Rationale: In pregnancy,
DIC activates clotting, forming micro clots. Risk factors: dead fetus
syndrome, severe preeclampsia(hypertensive), and hemorrhage (not 500
mL loss). A large newborn is not a risk factor. Correct Answers A
gravida II( second time pregnant )who has just been diagnosed with
dead fetus syndrome
A 28-year-old woman, G3P2, is 34 weeks pregnant and has been
receiving methadone maintenance therapy for opioid use disorder for
the past 2 years. She reports compliance with her methadone regimen
and is monitored regularly. She has no other significant medical history
and has not experienced any complications during this pregnancy.
Vital Signs:BP: 122/78 mmHgHR: 84 bpmRespiratory rate: 16
bpmTemp: 98.7°F
Assessment Findings:
The patient has no complaints of pain or distress.
No history of preterm labor or bleeding.
Fetal heart rate (FHR) is 138 bpm, reassuring.
Non-stress test (NST) shows reactive FHR with good variability.
Question: Which of the following interventions should the nurse
implement when caring for a pregnant woman on methadone
maintenance therapy? (Select all that apply) Correct Answers Monitor
, fetal heart rate (FHR) regularly for signs of distress. Educate the patient
about the importance of continuing methadone therapy throughout the
pregnancy.Collaborate with a multidisciplinary team to ensure
appropriate monitoring and support.. Assess the patient for signs of
opioid withdrawal, as withdrawal may occur if methadone is abruptly
discontinued.
A nurse is caring for a pregnant woman who is prescribed methadone
for opioid use disorder. Which of the following statements regarding
methadone therapy is correct? Key points:
Methadone is a first-line treatment for opioid use disorder in pregnancy.
Prevents withdrawal and reduces relapse risk. Avoid abrupt
discontinuation to prevent withdrawal in mother and fetus.
Neonatal Abstinence Syndrome (NAS) may occur but is treatable
Correct Answers Methadone is considered a first-line treatment for
opioid use disorder in pregnant women and is generally safe for the
fetus.
The nurse is caring for a client in labor. Which assessment findings
indicate to the nurse that the client is beginning the second stage of
labor? Select all that apply. Correct Answers The cervix is dilated
completely.
The Ferguson reflex is initiated from perineal pressure
The nurse in the labor room is caring for a client in the active stage of
the first phase of labor. The nurse is assessing the fetal patterns and
notes a late deceleration on the monitor strip. Key point to remember:
80QW/EXP, NAXLEX MOST TESTED EXAM QUESTIONS AND
ANSWERS GRADED A+ ASSURED SUCCESS
A client at 32 weeks gestation is hospitalized with severe pregnancy-
induced hypertension (PIH), and magnesium sulfate is prescribed to
control symptoms. Which assessment finding would indicate that
therapeutic drug level has been achieved? Correct Answers Urinary
output of 50 mL per hour.
The nurse is preparing to administer magnesium sulfate to a laboring
client whose blood pressure has risen from 110/60 mmHg to 140/90
mmHg. Which nursing protocol is of the highest priority? Correct
Answers Ensure calcium gluconate is immediately available
The nurse is about to administer phytonadione to a newborn. Which
statement by the parents shows they understand why this medication is
being given? Correct Answers It prevents hemorrhagic disorders.
A patient in early labor is receiving oxytocin and begins to experience
tach systolic or tetanic contractions with variable fetal heart
decelerations. What should the nurse do next? Correct Answers
Discontinue the oxytocin infusion.
A client at 28-weeks gestation whose hemoglobin level is 10.7 g/dL
(107 g/L) and hematocrit is 32.3% (0.323 volume fraction), tells the
nurse that she eats plenty of green vegetables. When the client asks the
nurse how the pregnancy might affect the laboratory findings, which
,information should the nurse provide? Correct Answers Plasma volume
increases, making the blood count appear low.
A 3-year-old male was brought into the emergency room this morning
with a sudden onset of "fast and noisy breathing". According to his
parents, he had sneezing and a runny nose last week but seemed to have
recovered. The child lives with 2 older, school-age siblings, his parents,
and 3 dogs. He was born at 37 weeks' gestation. The parents deny
smoking, but his grandmother cares for him in the afternoons and
smokes outside when she is at the house. He has no significant medical
history. He has received all vaccines except for those due at 3 years.
Upon exam, the child is... Which two items must the nurse ensure are
available before attempting to place the intravenous line? Correct
Answers Manual resuscitation bag, An advanced airway kit
The nurse is reviewing a client's chart.
Click to highlight areas of client history and physical below that
increase the risk for postpartum hemorrhage.
Client was middle-aged and married. She was in labor for 25 hours and
forceps were used to assist with the delivery. She was given an epidural
for anesthesia that was effective. The labor and delivery nurse reported
that the client had a 4th degree laceration, and her pain was currently at
a 4 on a 0 to 10 pain scale. Her vital signs were stable, and she was
catheterized for 500 mL of light-yellow urine just prior to delivery. Her
spouse was at the bedside for delivery. Correct Answers She was in
labor for 25 hours
,-forceps were used to assist with the delivery
-client had a 4th degree laceration
The nurse in a maternity unit is reviewing the clients' records. Which
client would the nurse identify as being at the most risk for developing
disseminated intravascular coagulation(DIC)?Rationale: In pregnancy,
DIC activates clotting, forming micro clots. Risk factors: dead fetus
syndrome, severe preeclampsia(hypertensive), and hemorrhage (not 500
mL loss). A large newborn is not a risk factor. Correct Answers A
gravida II( second time pregnant )who has just been diagnosed with
dead fetus syndrome
A 28-year-old woman, G3P2, is 34 weeks pregnant and has been
receiving methadone maintenance therapy for opioid use disorder for
the past 2 years. She reports compliance with her methadone regimen
and is monitored regularly. She has no other significant medical history
and has not experienced any complications during this pregnancy.
Vital Signs:BP: 122/78 mmHgHR: 84 bpmRespiratory rate: 16
bpmTemp: 98.7°F
Assessment Findings:
The patient has no complaints of pain or distress.
No history of preterm labor or bleeding.
Fetal heart rate (FHR) is 138 bpm, reassuring.
Non-stress test (NST) shows reactive FHR with good variability.
Question: Which of the following interventions should the nurse
implement when caring for a pregnant woman on methadone
maintenance therapy? (Select all that apply) Correct Answers Monitor
, fetal heart rate (FHR) regularly for signs of distress. Educate the patient
about the importance of continuing methadone therapy throughout the
pregnancy.Collaborate with a multidisciplinary team to ensure
appropriate monitoring and support.. Assess the patient for signs of
opioid withdrawal, as withdrawal may occur if methadone is abruptly
discontinued.
A nurse is caring for a pregnant woman who is prescribed methadone
for opioid use disorder. Which of the following statements regarding
methadone therapy is correct? Key points:
Methadone is a first-line treatment for opioid use disorder in pregnancy.
Prevents withdrawal and reduces relapse risk. Avoid abrupt
discontinuation to prevent withdrawal in mother and fetus.
Neonatal Abstinence Syndrome (NAS) may occur but is treatable
Correct Answers Methadone is considered a first-line treatment for
opioid use disorder in pregnant women and is generally safe for the
fetus.
The nurse is caring for a client in labor. Which assessment findings
indicate to the nurse that the client is beginning the second stage of
labor? Select all that apply. Correct Answers The cervix is dilated
completely.
The Ferguson reflex is initiated from perineal pressure
The nurse in the labor room is caring for a client in the active stage of
the first phase of labor. The nurse is assessing the fetal patterns and
notes a late deceleration on the monitor strip. Key point to remember:
