Labor & Delivery Saunders NCLEX (2025)
Actual Exam Questions and Answers A+
Graded
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?
.1.
A .primigravida .with .mild .preeclampsia
.2.
A .primigravida .who .delivered .a .10-lb .infant .3 .hours .ago
.3.
A .gravida .II .who .has .just .been .diagnosed .with .dead .fetus .syndrome
.4.
A .gravida .IV .who .delivered .8 .hours .ago .and .has .lost .500 .mL .of .blood .-
.CORRECT .ANSWER-3
In .a .pregnant .client, .disseminated .intravascular .coagulation .(DIC) .is .a .condition
.in .which .the .clotting .cascade .is .activated, .resulting .in .the .formation .of .clots .in
.the .microcirculation. .Dead .fetus .syndrome .is .considered .a .risk .factor .for .DIC.
.Severe .preeclampsia .is .considered .a .risk .factor .for .DIC; .a .mild .case .is .not.
.Delivering .a .large .newborn .is .not .considered .a .risk .factor .for .DIC. .Hemorrhage
.is .a .risk .factor .for .DIC; .however, .a .loss .of .500 .mL .is .not .considered
.hemorrhage.
he .nurse .is .caring .for .a .client .in .labor. .Which .assessment .finding .indicates .to
.the .nurse .that .the .client .is .beginning .the .second .stage .of .labor?
.1.
The .contractions .are .regular.
.2.
The .membranes .have .ruptured.
.3.
The .cervix .is .dilated .completely.
,.4.
The .client .begins .to .expel .clear .vaginal .fluid. .- .CORRECT .ANSWER-3.
The .second .stage .of .labor .begins .when .the .cervix .is .dilated .completely .and
.ends .with .birth .of .the .neonate. .Options .1, .2, .and .4 .are .not .specific .assessment
.findings .of .the .second .stage .of .labor .and .occur .in .stage .1.
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. .What .is .the .most .appropriate .nursing .action?
.1.
Administer .oxygen .via .face .mask.
.2.
Place .the .mother .in .a .supine .position.
.3.
Increase .the .rate .of .the .oxytocin .(Pitocin) .intravenous .infusion.
.4.
Document .the .findings .and .continue .to .monitor .the .fetal .patterns. .- .CORRECT
.ANSWER-1
Late .decelerations .are .due .to .uteroplacental .insufficiency .and .occur .because .of
.decreased .blood .flow .and .oxygen .to .the .fetus .during .the .uterine .contractions.
.Hypoxemia .results; .oxygen .at .8 .to .10 .L/minute .via .face .mask .is .necessary. .The
.supine .position .is .avoided .because .it .decreases .uterine .blood .flow .to .the
.fetus. .The .client .should .be .turned .onto .her .side .to .displace .pressure .of .the
.gravid .uterus .on .the .inferior .vena .cava. .An .intravenous .oxytocin .infusion .is
.discontinued .when .a .late .deceleration .is .noted. .The .oxytocin .would .cause
.further .hypoxemia .because .of .increased .uteroplacental .insufficiency .resulting
.from .stimulation .of .contractions .by .this .medication. .Although .the .nurse .would
.document .the .occurrence, .option .4 .would .delay .necessary .treatment.
The .nurse .is .performing .an .assessment .of .a .client .who .is .scheduled .for .a
.cesarean .delivery. .Which .assessment .finding .would .indicate .the .need .to
.contact .the .health .care .provider?
.1.
Hemoglobin .of .11 .g/dL
.2.
Fetal .heart .rate .of .180 .beats/minute
.3.
Maternal .pulse .rate .of .85 .beats/minute
.4.
,White .blood .cell .count .of .12,000 .cells/mm3 .- .CORRECT .ANSWER-2
A .normal .fetal .heart .rate .is .110 .to .160 .beats/minute. .A .fetal .heart .rate .of .180
.beats/minute .could .indicate .fetal .distress .and .would .warrant .immediate
.notification .of .the .HCP. .By .full .term, .a .normal .maternal .hemoglobin .range .is .11
.to .13 .g/dL .because .of .the .hemodilution .caused .by .an .increase .in .plasma
.volume .during .pregnancy. .The .maternal .pulse .rate .during .pregnancy .increases
.10 .to .15 .beats/minute .over .prepregnancy .readings .to .facilitate .increased
.cardiac .output, .oxygen .transport, .and .kidney .filtration. .White .blood .cell .counts
.in .a .normal .pregnancy .begin .to .increase .in .the .second .trimester .and .peak .in
.the .third .trimester, .with .a .normal .range .of .11,000 .to .15,000 .cells/mm3 .(up .to
.18,000 .cells/mm3). .During .the .immediate .postpartum .period, .the .white .blood
.cell .count .may .be .25,000 .to .30,000 .cells/mm3 .because .of .increased
.leukocytosis .that .occurs .during .delivery.
The .nurse .is .reviewing .the .record .of .a .client .in .the .labor .room .and .notes .that
.the .health .care .provider .has .documented .that .the .fetal .presenting .part .is .at .the
.-1 .station. .This .documented .finding .indicates .that .the .fetal .presenting .part .is
.located .at .which .area?
.1.
1 .inch .below .the .coccyx
.2.
1 .inch .below .the .iliac .crest
.3.
1 .cm .above .the .ischial .spine
.4.
1 .fingerbreadth .below .the .symphysis .pubis .- .CORRECT .ANSWER-3
Station .is .the .measurement .of .the .progress .of .descent .in .centimeters .above .or
.below .the .midplane .from .the .presenting .part .to .the .ischial .spine. .It .is
.measured .in .centimeters, .and .noted .as .a .negative .number .above .the .line .and
.as .a .positive .number .below .the .line. .At .the .negative .1 .(-1) .station, .the .fetal
.presenting .part .is .1 .cm .above .the .ischial .spine.
A .client .arrives .at .a .birthing .center .in .active .labor. .Her .membranes .are .still
.intact, .and .the .health .care .provider .prepares .to .perform .an .amniotomy. .What
.will .the .nurse .relay .to .the .client .as .the .most .likely .outcome .of .the .amniotomy?
.1.
Less .pressure .on .her .cervix
.2.
Decreased .number .of .contractions
.3.
, Increased .efficiency .of .contractions
.4.
The .need .for .increased .maternal .blood .pressure .monitoring .- .CORRECT
.ANSWER-3
Amniotomy .(artificial .rupture .of .the .membranes) .can .be .used .to .induce .labor
.when .the .condition .of .the .cervix .is .favorable .(ripe) .or .to .augment .labor .if .the
.progress .begins .to .slow. .Rupturing .of .the .membranes .allows .the .fetal .head .to
.contact .the .cervix .more .directly .and .may .increase .the .efficiency .of
.contractions. .Increased .monitoring .of .maternal .blood .pressure .is .unnecessary
.following .this .procedure. .The .fetal .heart .rate .needs .to .be .monitored .frequently,
.however.
The .nurse .is .monitoring .a .client .in .labor. .The .nurse .suspects .umbilical .cord
.compression .if .which .is .noted .on .the .external .monitor .tracing .during .a
.contraction?
.1.
Variability
.2.
Accelerations
.3.
Early .decelerations
.4.
Variable .decelerations .- .CORRECT .ANSWER-4
Variable .decelerations .occur .if .the .umbilical .cord .becomes .compressed,
.reducing .blood .flow .between .the .placenta .and .the .fetus. .Variability .refers .to
.fluctuations .in .the .baseline .fetal .heart .rate. .Accelerations .are .a .reassuring .sign
.and .usually .occur .with .fetal .movement. .Early .decelerations .result .from
.pressure .on .the .fetal .head .during .a .contraction.
A .client .in .labor .is .transported .to .the .delivery .room .and .prepared .for .a
.cesarean .delivery. .After .the .client .is .transferred .to .the .delivery .room .table, .the
.nurse .should .place .the .client .in .which .position?
.1.
Supine .position .with .a .wedge .under .the .right .hip
.2.
Trendelenburg's .position .with .the .legs .in .stirrups
.3.
Prone .position .with .the .legs .separated .and .elevated
Actual Exam Questions and Answers A+
Graded
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?
.1.
A .primigravida .with .mild .preeclampsia
.2.
A .primigravida .who .delivered .a .10-lb .infant .3 .hours .ago
.3.
A .gravida .II .who .has .just .been .diagnosed .with .dead .fetus .syndrome
.4.
A .gravida .IV .who .delivered .8 .hours .ago .and .has .lost .500 .mL .of .blood .-
.CORRECT .ANSWER-3
In .a .pregnant .client, .disseminated .intravascular .coagulation .(DIC) .is .a .condition
.in .which .the .clotting .cascade .is .activated, .resulting .in .the .formation .of .clots .in
.the .microcirculation. .Dead .fetus .syndrome .is .considered .a .risk .factor .for .DIC.
.Severe .preeclampsia .is .considered .a .risk .factor .for .DIC; .a .mild .case .is .not.
.Delivering .a .large .newborn .is .not .considered .a .risk .factor .for .DIC. .Hemorrhage
.is .a .risk .factor .for .DIC; .however, .a .loss .of .500 .mL .is .not .considered
.hemorrhage.
he .nurse .is .caring .for .a .client .in .labor. .Which .assessment .finding .indicates .to
.the .nurse .that .the .client .is .beginning .the .second .stage .of .labor?
.1.
The .contractions .are .regular.
.2.
The .membranes .have .ruptured.
.3.
The .cervix .is .dilated .completely.
,.4.
The .client .begins .to .expel .clear .vaginal .fluid. .- .CORRECT .ANSWER-3.
The .second .stage .of .labor .begins .when .the .cervix .is .dilated .completely .and
.ends .with .birth .of .the .neonate. .Options .1, .2, .and .4 .are .not .specific .assessment
.findings .of .the .second .stage .of .labor .and .occur .in .stage .1.
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. .What .is .the .most .appropriate .nursing .action?
.1.
Administer .oxygen .via .face .mask.
.2.
Place .the .mother .in .a .supine .position.
.3.
Increase .the .rate .of .the .oxytocin .(Pitocin) .intravenous .infusion.
.4.
Document .the .findings .and .continue .to .monitor .the .fetal .patterns. .- .CORRECT
.ANSWER-1
Late .decelerations .are .due .to .uteroplacental .insufficiency .and .occur .because .of
.decreased .blood .flow .and .oxygen .to .the .fetus .during .the .uterine .contractions.
.Hypoxemia .results; .oxygen .at .8 .to .10 .L/minute .via .face .mask .is .necessary. .The
.supine .position .is .avoided .because .it .decreases .uterine .blood .flow .to .the
.fetus. .The .client .should .be .turned .onto .her .side .to .displace .pressure .of .the
.gravid .uterus .on .the .inferior .vena .cava. .An .intravenous .oxytocin .infusion .is
.discontinued .when .a .late .deceleration .is .noted. .The .oxytocin .would .cause
.further .hypoxemia .because .of .increased .uteroplacental .insufficiency .resulting
.from .stimulation .of .contractions .by .this .medication. .Although .the .nurse .would
.document .the .occurrence, .option .4 .would .delay .necessary .treatment.
The .nurse .is .performing .an .assessment .of .a .client .who .is .scheduled .for .a
.cesarean .delivery. .Which .assessment .finding .would .indicate .the .need .to
.contact .the .health .care .provider?
.1.
Hemoglobin .of .11 .g/dL
.2.
Fetal .heart .rate .of .180 .beats/minute
.3.
Maternal .pulse .rate .of .85 .beats/minute
.4.
,White .blood .cell .count .of .12,000 .cells/mm3 .- .CORRECT .ANSWER-2
A .normal .fetal .heart .rate .is .110 .to .160 .beats/minute. .A .fetal .heart .rate .of .180
.beats/minute .could .indicate .fetal .distress .and .would .warrant .immediate
.notification .of .the .HCP. .By .full .term, .a .normal .maternal .hemoglobin .range .is .11
.to .13 .g/dL .because .of .the .hemodilution .caused .by .an .increase .in .plasma
.volume .during .pregnancy. .The .maternal .pulse .rate .during .pregnancy .increases
.10 .to .15 .beats/minute .over .prepregnancy .readings .to .facilitate .increased
.cardiac .output, .oxygen .transport, .and .kidney .filtration. .White .blood .cell .counts
.in .a .normal .pregnancy .begin .to .increase .in .the .second .trimester .and .peak .in
.the .third .trimester, .with .a .normal .range .of .11,000 .to .15,000 .cells/mm3 .(up .to
.18,000 .cells/mm3). .During .the .immediate .postpartum .period, .the .white .blood
.cell .count .may .be .25,000 .to .30,000 .cells/mm3 .because .of .increased
.leukocytosis .that .occurs .during .delivery.
The .nurse .is .reviewing .the .record .of .a .client .in .the .labor .room .and .notes .that
.the .health .care .provider .has .documented .that .the .fetal .presenting .part .is .at .the
.-1 .station. .This .documented .finding .indicates .that .the .fetal .presenting .part .is
.located .at .which .area?
.1.
1 .inch .below .the .coccyx
.2.
1 .inch .below .the .iliac .crest
.3.
1 .cm .above .the .ischial .spine
.4.
1 .fingerbreadth .below .the .symphysis .pubis .- .CORRECT .ANSWER-3
Station .is .the .measurement .of .the .progress .of .descent .in .centimeters .above .or
.below .the .midplane .from .the .presenting .part .to .the .ischial .spine. .It .is
.measured .in .centimeters, .and .noted .as .a .negative .number .above .the .line .and
.as .a .positive .number .below .the .line. .At .the .negative .1 .(-1) .station, .the .fetal
.presenting .part .is .1 .cm .above .the .ischial .spine.
A .client .arrives .at .a .birthing .center .in .active .labor. .Her .membranes .are .still
.intact, .and .the .health .care .provider .prepares .to .perform .an .amniotomy. .What
.will .the .nurse .relay .to .the .client .as .the .most .likely .outcome .of .the .amniotomy?
.1.
Less .pressure .on .her .cervix
.2.
Decreased .number .of .contractions
.3.
, Increased .efficiency .of .contractions
.4.
The .need .for .increased .maternal .blood .pressure .monitoring .- .CORRECT
.ANSWER-3
Amniotomy .(artificial .rupture .of .the .membranes) .can .be .used .to .induce .labor
.when .the .condition .of .the .cervix .is .favorable .(ripe) .or .to .augment .labor .if .the
.progress .begins .to .slow. .Rupturing .of .the .membranes .allows .the .fetal .head .to
.contact .the .cervix .more .directly .and .may .increase .the .efficiency .of
.contractions. .Increased .monitoring .of .maternal .blood .pressure .is .unnecessary
.following .this .procedure. .The .fetal .heart .rate .needs .to .be .monitored .frequently,
.however.
The .nurse .is .monitoring .a .client .in .labor. .The .nurse .suspects .umbilical .cord
.compression .if .which .is .noted .on .the .external .monitor .tracing .during .a
.contraction?
.1.
Variability
.2.
Accelerations
.3.
Early .decelerations
.4.
Variable .decelerations .- .CORRECT .ANSWER-4
Variable .decelerations .occur .if .the .umbilical .cord .becomes .compressed,
.reducing .blood .flow .between .the .placenta .and .the .fetus. .Variability .refers .to
.fluctuations .in .the .baseline .fetal .heart .rate. .Accelerations .are .a .reassuring .sign
.and .usually .occur .with .fetal .movement. .Early .decelerations .result .from
.pressure .on .the .fetal .head .during .a .contraction.
A .client .in .labor .is .transported .to .the .delivery .room .and .prepared .for .a
.cesarean .delivery. .After .the .client .is .transferred .to .the .delivery .room .table, .the
.nurse .should .place .the .client .in .which .position?
.1.
Supine .position .with .a .wedge .under .the .right .hip
.2.
Trendelenburg's .position .with .the .legs .in .stirrups
.3.
Prone .position .with .the .legs .separated .and .elevated
