Labor & Delivery Saunders NCLEX
questions 80Qw/exp
The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse
I I I I I I I I I I I I I I I
identify as being at the most risk for developing disseminated intravascular coagulation?
I I I I I I I I I I I I
1. I
A primigravida with mild preeclampsia
I I I I
2. I
A primigravida who delivered a 10-lb infant 3 hours ago
I I I I I I I I I
3. I
A gravida II who has just been diagnosed with dead fetus syndrome
I I I I I I I I I I I
4. I
A gravida IV who delivered 8 hours ago and has lost 500 mL of blood - Correct Answers 3
I I I I I I I I I I I I I I I II I IIII
In a pregnant client, disseminated intravascular coagulation (DIC) is a condition in which the
I I I I I I I I I I I I I
clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead
I I I I I I I I I I I I I I
fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk
I I I I I I I I I I I I I I I
factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for
I I I I I I I I I I I I I I I I I I I
DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered
I I I I I I I I I I I I I I I I I
hemorrhage.
I
he nurse is caring for a client in labor. Which assessment finding indicates to the nurse that
I I I I I I I I I I I I I I I I I
the client is beginning the second stage of labor?
I I I I I I I I I
1. I
The contractions are regular.
I I I
2. I
The membranes have ruptured.I I I
3. I
The cervix is dilated completely.
I I I I
4. I
The client begins to expel clear vaginal fluid. - Correct Answers 3.
I I I I I I I I II I IIII
The second stage of labor begins when the cervix is dilated completely and ends with birth of
I I I I I I I I I I I I I I I I
the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of
I I I I I I I I I I I I I I I I I
labor and occur in stage 1.
I I I I I I
,The nurse in the labor room is caring for a client in the active stage of the first phase of labor.
I I I I I I I I I I I I I I I I I I I I I
The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip.
I I I I I I I I I I I I I I I I
What is the most appropriate nursing action?
I I I I I I I
1. I
Administer oxygen via face mask. I I I I
2. I
Place the mother in a supine position.
I I I I I I
3. I
Increase the rate of the oxytocin (Pitocin) intravenous infusion.
I I I I I I I I
4. I
Document the findings and continue to monitor the fetal patterns. - Correct Answers 1
I I I I I I I I I I II I IIII
Late decelerations are due to uteroplacental insufficiency and occur because of decreased
I I I I I I I I I I I
blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results;
I I I I I I I I I I I I I
oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided
I I I I I I I I I I I I I I I I
because it decreases uterine blood flow to the fetus. The client should be turned onto her
I I I I I I I I I I I I I I I I
side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous
I I I I I I I I I I I I I I I
oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would
I I I I I I I I I I I I I
cause further hypoxemia because of increased uteroplacental insufficiency resulting from
I I I I I I I I I I
stimulation of contractions by this medication. Although the nurse would document the
I I I I I I I I I I I I
occurrence, option 4 would delay necessary treatment.
I I I I I I I
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery.
I I I I I I I I I I I I I I I I
Which assessment finding would indicate the need to contact the health care provider?
I I I I I I I I I I I I I
1. I
Hemoglobin of 11 g/dL I I I
2. I
Fetal heart rate of 180 beats/minute
I I I I I
3. I
Maternal pulse rate of 85 beats/minute I I I I I
4. I
White blood cell count of 12,000 cells/mm3 - Correct Answers 2
I I I I I I I II I IIII
A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute
I I I I I I I I I I I I I I I I
could indicate fetal distress and would warrant immediate notification of the HCP. By full
I I I I I I I I I I I I I I
term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution
I I I I I I I I I I I I I I I
caused by an increase in plasma volume during pregnancy. The maternal pulse rate during
I I I I I I I I I I I I I I
pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate
I I I I I I I I I I I
,increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in
I I I I I I I I I I I I I
a normal pregnancy begin to increase in the second trimester and peak in the third trimester,
I I I I I I I I I I I I I I I I
with a normal range of 11,000 to 15,000 cells/mm3 (up to 18,000 cells/mm3). During the
I I I I I I I I I I I I I I I
immediate postpartum period, the white blood cell count may be 25,000 to 30,000
I I I I I I I I I I I I I
cells/mm3 because of increased leukocytosis that occurs during delivery.
I I I I I I I I I
The nurse is reviewing the record of a client in the labor room and notes that the health care
I I I I I I I I I I I I I I I I I I I
provider has documented that the fetal presenting part is at the -1 station. This documented
I I I I I I I I I I I I I I I
finding indicates that the fetal presenting part is located at which area?
I I I I I I I I I I I I
1. I
1 inch below the coccyx
I I I I
2. I
1 inch below the iliac crest
I I I I I
3. I
1 cm above the ischial spine
I I I I I
4. I
1 fingerbreadth below the symphysis pubis - Correct Answers 3
I I I I I I II I IIII
Station is the measurement of the progress of descent in centimeters above or below the
I I I I I I I I I I I I I I
midplane from the presenting part to the ischial spine. It is measured in centimeters, and
I I I I I I I I I I I I I I I
noted as a negative number above the line and as a positive number below the line. At the
I I I I I I I I I I I I I I I I I I
negative 1 (-1) station, the fetal presenting part is 1 cm above the ischial spine.
I I I I I I I I I I I I I I I
A client arrives at a birthing center in active labor. Her membranes are still intact, and the
I I I I I I I I I I I I I I I I I
health care provider prepares to perform an amniotomy. What will the nurse relay to the
I I I I I I I I I I I I I I I
client as the most likely outcome of the amniotomy?
I I I I I I I I I
1. I
Less pressure on her cervix I I I I
2. I
Decreased number of contractions I I I
3. I
Increased efficiency of contractions I I I
4. I
The need for increased maternal blood pressure monitoring - Correct Answers 3
I I I I I I I I II I IIII
Amniotomy (artificial rupture of the membranes) can be used to induce labor when the I I I I I I I I I I I I I
condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow.
I I I I I I I I I I I I I I I I I
Rupturing of the membranes allows the fetal head to contact the cervix more directly and
I I I I I I I I I I I I I I I
, may increase the efficiency of contractions. Increased monitoring of maternal blood
I I I I I I I I I I I
pressure is unnecessary following this procedure. The fetal heart rate needs to be
I I I I I I I I I I I I I
monitored frequently, however.
I I I
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if
I I I I I I I I I I I I I I I
I which is noted on the external monitor tracing during a contraction?
I I I I I I I I I I
1. I
Variability
2. I
Accelerations
3. I
Early decelerations I
4. I
Variable decelerations - Correct Answers 4 I I II I IIII
Variable decelerations occur if the umbilical cord becomes compressed, reducing blood
I I I I I I I I I I
flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal
I I I I I I I I I I I I I I I
heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early
I I I I I I I I I I I I I I
decelerations result from pressure on the fetal head during a contraction.
I I I I I I I I I I I
A client in labor is transported to the delivery room and prepared for a cesarean delivery.
I I I I I I I I I I I I I I I I
After the client is transferred to the delivery room table, the nurse should place the client in
I I I I I I I I I I I I I I I I I
which position?
I I
1. I
Supine position with a wedge under the right hipI I I I I I I I
2. I
Trendelenburg's position with the legs in stirrups I I I I I I
3. I
Prone position with the legs separated and elevated
I I I I I I I
4. I
Semi-Fowler's position with a pillow under the knees - Correct Answers 1 I I I I I I I I II I IIII
Vena cava and descending aorta compression by the pregnant uterus impedes blood return
I I I I I I I I I I I I
from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac
I I I I I I I I I I I I I
output, and blood flow to the uterus and subsequently the fetus. The best position to prevent
I I I I I I I I I I I I I I I I
this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for
I I I I I I I I I I I I I I
abdominal surgery necessitates a supine position, however; a wedge placed under the right
I I I I I I I I I I I I I
hip provides displacement of the uterus. Trendelenburg's position places pressure from the
I I I I I I I I I I I I
questions 80Qw/exp
The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse
I I I I I I I I I I I I I I I
identify as being at the most risk for developing disseminated intravascular coagulation?
I I I I I I I I I I I I
1. I
A primigravida with mild preeclampsia
I I I I
2. I
A primigravida who delivered a 10-lb infant 3 hours ago
I I I I I I I I I
3. I
A gravida II who has just been diagnosed with dead fetus syndrome
I I I I I I I I I I I
4. I
A gravida IV who delivered 8 hours ago and has lost 500 mL of blood - Correct Answers 3
I I I I I I I I I I I I I I I II I IIII
In a pregnant client, disseminated intravascular coagulation (DIC) is a condition in which the
I I I I I I I I I I I I I
clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead
I I I I I I I I I I I I I I
fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk
I I I I I I I I I I I I I I I
factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for
I I I I I I I I I I I I I I I I I I I
DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered
I I I I I I I I I I I I I I I I I
hemorrhage.
I
he nurse is caring for a client in labor. Which assessment finding indicates to the nurse that
I I I I I I I I I I I I I I I I I
the client is beginning the second stage of labor?
I I I I I I I I I
1. I
The contractions are regular.
I I I
2. I
The membranes have ruptured.I I I
3. I
The cervix is dilated completely.
I I I I
4. I
The client begins to expel clear vaginal fluid. - Correct Answers 3.
I I I I I I I I II I IIII
The second stage of labor begins when the cervix is dilated completely and ends with birth of
I I I I I I I I I I I I I I I I
the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of
I I I I I I I I I I I I I I I I I
labor and occur in stage 1.
I I I I I I
,The nurse in the labor room is caring for a client in the active stage of the first phase of labor.
I I I I I I I I I I I I I I I I I I I I I
The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip.
I I I I I I I I I I I I I I I I
What is the most appropriate nursing action?
I I I I I I I
1. I
Administer oxygen via face mask. I I I I
2. I
Place the mother in a supine position.
I I I I I I
3. I
Increase the rate of the oxytocin (Pitocin) intravenous infusion.
I I I I I I I I
4. I
Document the findings and continue to monitor the fetal patterns. - Correct Answers 1
I I I I I I I I I I II I IIII
Late decelerations are due to uteroplacental insufficiency and occur because of decreased
I I I I I I I I I I I
blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results;
I I I I I I I I I I I I I
oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided
I I I I I I I I I I I I I I I I
because it decreases uterine blood flow to the fetus. The client should be turned onto her
I I I I I I I I I I I I I I I I
side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous
I I I I I I I I I I I I I I I
oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would
I I I I I I I I I I I I I
cause further hypoxemia because of increased uteroplacental insufficiency resulting from
I I I I I I I I I I
stimulation of contractions by this medication. Although the nurse would document the
I I I I I I I I I I I I
occurrence, option 4 would delay necessary treatment.
I I I I I I I
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery.
I I I I I I I I I I I I I I I I
Which assessment finding would indicate the need to contact the health care provider?
I I I I I I I I I I I I I
1. I
Hemoglobin of 11 g/dL I I I
2. I
Fetal heart rate of 180 beats/minute
I I I I I
3. I
Maternal pulse rate of 85 beats/minute I I I I I
4. I
White blood cell count of 12,000 cells/mm3 - Correct Answers 2
I I I I I I I II I IIII
A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute
I I I I I I I I I I I I I I I I
could indicate fetal distress and would warrant immediate notification of the HCP. By full
I I I I I I I I I I I I I I
term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution
I I I I I I I I I I I I I I I
caused by an increase in plasma volume during pregnancy. The maternal pulse rate during
I I I I I I I I I I I I I I
pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate
I I I I I I I I I I I
,increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in
I I I I I I I I I I I I I
a normal pregnancy begin to increase in the second trimester and peak in the third trimester,
I I I I I I I I I I I I I I I I
with a normal range of 11,000 to 15,000 cells/mm3 (up to 18,000 cells/mm3). During the
I I I I I I I I I I I I I I I
immediate postpartum period, the white blood cell count may be 25,000 to 30,000
I I I I I I I I I I I I I
cells/mm3 because of increased leukocytosis that occurs during delivery.
I I I I I I I I I
The nurse is reviewing the record of a client in the labor room and notes that the health care
I I I I I I I I I I I I I I I I I I I
provider has documented that the fetal presenting part is at the -1 station. This documented
I I I I I I I I I I I I I I I
finding indicates that the fetal presenting part is located at which area?
I I I I I I I I I I I I
1. I
1 inch below the coccyx
I I I I
2. I
1 inch below the iliac crest
I I I I I
3. I
1 cm above the ischial spine
I I I I I
4. I
1 fingerbreadth below the symphysis pubis - Correct Answers 3
I I I I I I II I IIII
Station is the measurement of the progress of descent in centimeters above or below the
I I I I I I I I I I I I I I
midplane from the presenting part to the ischial spine. It is measured in centimeters, and
I I I I I I I I I I I I I I I
noted as a negative number above the line and as a positive number below the line. At the
I I I I I I I I I I I I I I I I I I
negative 1 (-1) station, the fetal presenting part is 1 cm above the ischial spine.
I I I I I I I I I I I I I I I
A client arrives at a birthing center in active labor. Her membranes are still intact, and the
I I I I I I I I I I I I I I I I I
health care provider prepares to perform an amniotomy. What will the nurse relay to the
I I I I I I I I I I I I I I I
client as the most likely outcome of the amniotomy?
I I I I I I I I I
1. I
Less pressure on her cervix I I I I
2. I
Decreased number of contractions I I I
3. I
Increased efficiency of contractions I I I
4. I
The need for increased maternal blood pressure monitoring - Correct Answers 3
I I I I I I I I II I IIII
Amniotomy (artificial rupture of the membranes) can be used to induce labor when the I I I I I I I I I I I I I
condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow.
I I I I I I I I I I I I I I I I I
Rupturing of the membranes allows the fetal head to contact the cervix more directly and
I I I I I I I I I I I I I I I
, may increase the efficiency of contractions. Increased monitoring of maternal blood
I I I I I I I I I I I
pressure is unnecessary following this procedure. The fetal heart rate needs to be
I I I I I I I I I I I I I
monitored frequently, however.
I I I
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if
I I I I I I I I I I I I I I I
I which is noted on the external monitor tracing during a contraction?
I I I I I I I I I I
1. I
Variability
2. I
Accelerations
3. I
Early decelerations I
4. I
Variable decelerations - Correct Answers 4 I I II I IIII
Variable decelerations occur if the umbilical cord becomes compressed, reducing blood
I I I I I I I I I I
flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal
I I I I I I I I I I I I I I I
heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early
I I I I I I I I I I I I I I
decelerations result from pressure on the fetal head during a contraction.
I I I I I I I I I I I
A client in labor is transported to the delivery room and prepared for a cesarean delivery.
I I I I I I I I I I I I I I I I
After the client is transferred to the delivery room table, the nurse should place the client in
I I I I I I I I I I I I I I I I I
which position?
I I
1. I
Supine position with a wedge under the right hipI I I I I I I I
2. I
Trendelenburg's position with the legs in stirrups I I I I I I
3. I
Prone position with the legs separated and elevated
I I I I I I I
4. I
Semi-Fowler's position with a pillow under the knees - Correct Answers 1 I I I I I I I I II I IIII
Vena cava and descending aorta compression by the pregnant uterus impedes blood return
I I I I I I I I I I I I
from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac
I I I I I I I I I I I I I
output, and blood flow to the uterus and subsequently the fetus. The best position to prevent
I I I I I I I I I I I I I I I I
this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for
I I I I I I I I I I I I I I
abdominal surgery necessitates a supine position, however; a wedge placed under the right
I I I I I I I I I I I I I
hip provides displacement of the uterus. Trendelenburg's position places pressure from the
I I I I I I I I I I I I
