NURS 326 MATERNAL CHILD NURSING EXAM 2-
2025|100+Qs&As WITH
RATIONALES|CHAMBERLAIN COLLEGE
A nurse is caring for a patient in labor. Which observation by the nurse would
indicate that the second stage of labor, the descent phase, has begun?
a. The presenting part is below the ischial spines.
b. The amniotic membranes rupture.
c. The woman experiences a strong urge to bear down.
d. The cervix cannot be felt during a vaginal examination.
d. The cervix cannot be felt during a vaginal examination.
Rationale: The second stage of labor begins with full cervical dilation
A nurse is reviewing the concept of normal labor. Which statement should the
nurse indicate as being incorrect?
a. A regular progression of contractions, effacement, dilation, and descent occurs.
b. It is completed within 8 hours.
c. A single fetus presents by vertex.
d. No complications are involved.
b. It is completed within 8 hours.
Rationale: Although the amount of time varies with each woman, a normal
uncomplicated labor is usually completed within 18 hours. In normal labor, a
single fetus presents by vertex. A regular progression of contractions, effacement,
dilation, and descent is the trajectory that the nurse expects for a woman
experiencing a normal labor, which usually occurs with no complications.
,Nurses can help their clients by keeping them informed about the distinctive
stages of labor. What description should a nurse indicate as being accurate with
regard to the phases of the first stage of labor?
a. Lull: no contractions; dilation stable; duration of 20 to 60 minutes
b. Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4
hours
c. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6
hours
d. Transition: very strong but irregular contractions; 8 to 10 cm dilation;
duration of 1 to 2 hours
c. Active: moderate, regular contractions; 4 to 7 cm dilation;
duration of 3 to 6 hours
A nurse is working with a client in the second-stage of labor. Which position
would the nurse suggest if the pelvic outlet needs to be increased?
a. Semirecumbent
b. Side-lying
c. Sitting
d. Squatting
d. Squatting
A nurse is reviewing concepts relative to fetal circulation. Which factor should
the nurse identify as not affecting fetal circulation during labor?
a. Fetal position
b. Uterine contractions
,c. Blood pressure
d. Umbilical cord blood flow
a. Fetal position
Rationale: Maternal position may affect fetal circulation; however, fetal
position is unlikely to disturb umbilical blood flow.
A nurse is taking care of a client in the third stage of labor. Which statement
should the nurse identify as correct?
a. The duration of the third stage may be as short as 3 to 5 minutes.
b. The major risk for women during the third stage is a rapid heart rate.
c. The placenta eventually detaches itself from a flaccid uterus.
d. It is important that the dark, roughened maternal surface of the placenta
appear before the shiny fetal surface.
a. The duration of the third stage may be as short as 3 to 5 minutes.
Rationale: The third stage of labor lasts from birth of the fetus until the placenta
is delivered. The duration may be as short as 3 to 5 minutes, although up to 1
hour is considered within normal limits. The placenta cannot detach itself from a
flaccid (relaxed) uterus. Which surface of the placenta comes out first is not
clinically important. The major risk for women during the third stage of labor is
postpartum hemorrhage
A nurse is monitoring an obstetric client who is in early labor. Which of the
following findings would be a cause for concern if observed by the nurse? (Select
all that apply.)
a. Android pelvis
b. Biparietal diameter of less than 9.25 cm
, c. Vertex presenting part
d. General flexion attitude
e. Transverse lie
a, b, and e
A nurse teaches a pregnant woman about the characteristics of true labor
contractions. Which of the following statements indicates that the client correctly
undersands the nurse's instruction?
a. "True labor contractions will cause discomfort over the top of my uterus."
b. "True labor contractions will subside when I walk around."
c. "True labor contractions will continue and get stronger even if I relax and take
a shower."
d. "True labor contractions will remain irregular but become stronger."
c. "True labor contractions will continue and get stronger even if I
relax and take a shower."
A nurse is working on the labor and delivery unit. Under which circumstance
would a nurse not perform a vaginal examination on a client in labor?
a. When accelerations of the fetal heart rate (FHR) are noted
b. An admission to the hospital at the start of labor
c. When membranes rupture
d. On maternal perception of perineal pressure or the urge to bear down
a. When accelerations of the fetal heart rate (FHR) are noted
Rationale: An accelerated FHR is a positive sign not requiring vaginal
examination; variable decelerations, however, merit a vaginal examination.
2025|100+Qs&As WITH
RATIONALES|CHAMBERLAIN COLLEGE
A nurse is caring for a patient in labor. Which observation by the nurse would
indicate that the second stage of labor, the descent phase, has begun?
a. The presenting part is below the ischial spines.
b. The amniotic membranes rupture.
c. The woman experiences a strong urge to bear down.
d. The cervix cannot be felt during a vaginal examination.
d. The cervix cannot be felt during a vaginal examination.
Rationale: The second stage of labor begins with full cervical dilation
A nurse is reviewing the concept of normal labor. Which statement should the
nurse indicate as being incorrect?
a. A regular progression of contractions, effacement, dilation, and descent occurs.
b. It is completed within 8 hours.
c. A single fetus presents by vertex.
d. No complications are involved.
b. It is completed within 8 hours.
Rationale: Although the amount of time varies with each woman, a normal
uncomplicated labor is usually completed within 18 hours. In normal labor, a
single fetus presents by vertex. A regular progression of contractions, effacement,
dilation, and descent is the trajectory that the nurse expects for a woman
experiencing a normal labor, which usually occurs with no complications.
,Nurses can help their clients by keeping them informed about the distinctive
stages of labor. What description should a nurse indicate as being accurate with
regard to the phases of the first stage of labor?
a. Lull: no contractions; dilation stable; duration of 20 to 60 minutes
b. Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4
hours
c. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6
hours
d. Transition: very strong but irregular contractions; 8 to 10 cm dilation;
duration of 1 to 2 hours
c. Active: moderate, regular contractions; 4 to 7 cm dilation;
duration of 3 to 6 hours
A nurse is working with a client in the second-stage of labor. Which position
would the nurse suggest if the pelvic outlet needs to be increased?
a. Semirecumbent
b. Side-lying
c. Sitting
d. Squatting
d. Squatting
A nurse is reviewing concepts relative to fetal circulation. Which factor should
the nurse identify as not affecting fetal circulation during labor?
a. Fetal position
b. Uterine contractions
,c. Blood pressure
d. Umbilical cord blood flow
a. Fetal position
Rationale: Maternal position may affect fetal circulation; however, fetal
position is unlikely to disturb umbilical blood flow.
A nurse is taking care of a client in the third stage of labor. Which statement
should the nurse identify as correct?
a. The duration of the third stage may be as short as 3 to 5 minutes.
b. The major risk for women during the third stage is a rapid heart rate.
c. The placenta eventually detaches itself from a flaccid uterus.
d. It is important that the dark, roughened maternal surface of the placenta
appear before the shiny fetal surface.
a. The duration of the third stage may be as short as 3 to 5 minutes.
Rationale: The third stage of labor lasts from birth of the fetus until the placenta
is delivered. The duration may be as short as 3 to 5 minutes, although up to 1
hour is considered within normal limits. The placenta cannot detach itself from a
flaccid (relaxed) uterus. Which surface of the placenta comes out first is not
clinically important. The major risk for women during the third stage of labor is
postpartum hemorrhage
A nurse is monitoring an obstetric client who is in early labor. Which of the
following findings would be a cause for concern if observed by the nurse? (Select
all that apply.)
a. Android pelvis
b. Biparietal diameter of less than 9.25 cm
, c. Vertex presenting part
d. General flexion attitude
e. Transverse lie
a, b, and e
A nurse teaches a pregnant woman about the characteristics of true labor
contractions. Which of the following statements indicates that the client correctly
undersands the nurse's instruction?
a. "True labor contractions will cause discomfort over the top of my uterus."
b. "True labor contractions will subside when I walk around."
c. "True labor contractions will continue and get stronger even if I relax and take
a shower."
d. "True labor contractions will remain irregular but become stronger."
c. "True labor contractions will continue and get stronger even if I
relax and take a shower."
A nurse is working on the labor and delivery unit. Under which circumstance
would a nurse not perform a vaginal examination on a client in labor?
a. When accelerations of the fetal heart rate (FHR) are noted
b. An admission to the hospital at the start of labor
c. When membranes rupture
d. On maternal perception of perineal pressure or the urge to bear down
a. When accelerations of the fetal heart rate (FHR) are noted
Rationale: An accelerated FHR is a positive sign not requiring vaginal
examination; variable decelerations, however, merit a vaginal examination.
