Labor & Delivery Practice Exam Questions and Verified Answers| 100% Correct (2023/2024 Update)

Question 1 See full question While a 31-year-old multigravida at 39 weeks’ gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client’s cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first? You Selected:  Prepare the client for imminent birth. Correct response:  Note the color, amount, and odor of the amniotic fluid. Explanation: The nurse’s first action when membranes rupture spontaneously is to check the odor, consistency, and volume of the amniotic fluid. Because the fetal head is engaged and at 0 station, there is little likelihood of cord prolapse. However, when the fetal head is not engaged, checking for cord prolapse would be the priority when the membranes rupture spontaneously. After rupture of the membranes, vaginal examinations should be kept to a minimum to decrease the chance of infection. Although auscultating the client’s blood pressure is important, it is not the priority following spontaneous rupture of membranes. Birth is not imminent if the client is 5 cm dilated. However, multigravid clients may progress quickly in labor, especially after rupture of the membranes. Remediation: Question 2 See full question What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? You Selected:  beginning of one contraction to the beginning of the next contraction Correct response:  beginning of one contraction to the beginning of the next contraction Explanation: To assess the frequency of the client’s contractions, the nurse should assess the interval from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the interval between the beginning and the end of a contraction. The acme identifies the peak of a contraction. Remediation: Question 3 See full question The primary health care provider (HCP) prescribes whole blood replacement for a multigravid client with abruptio placentae. Before administering the intravenous blood product, the nurse should first: You Selected:  ask the client if she has ever had any allergies. Correct response:  validate client information and the blood product with another nurse. Explanation: When administering blood replacement therapy, extreme caution is needed. Before administering any blood product, the nurse should validate the client information and the blood product with another nurse to prevent administration of the wrong blood transfusion. Although baseline vital signs are necessary, she should initiate the infusion of blood slowly for the first 10 to 15 minutes. Then, if there is no evidence of a reaction, she should adjust the rate of infusion to ensure that the blood product is infused over 2 to 4 hours. The nurse can ask the client if she has ever had a reaction to a blood product, but a general question about allergies may not elicit the most complete response about any reactions to blood product administration. Blood transfusions are typically given with intravenous normal saline solution, not dextrose solutions. Remediation: Question 4 See full question A client at 36 weeks' gestation is admitted in preterm labor with a temperature of 101.2° F (38.4° C). She reports a steady dripping from the vaginal area and examination indicates that she's leaking amniotic fluid. A nurse realizes the probable cause of her fever is: You Selected:  a normal response to labor. Correct response:  intrauterine infection..