OB NCLEX Qs Intrapartum EXAM QUESTIONS AND CORRECT
ANSWERS VERIFIED 100%
When assessing a client who has just delivered a neonate, the nurse finds that
the fundus is boggy and deviated to the right. What should the nurse do?
1. Have the client void.
2. Assess the client's vital signs.
3. Evaluate lochia characteristics.
4. Massage the fundus.
Answer: 1 - Having the client void can determine whether the boggy, deviated fundus
results from a full bladder — the most common cause of these fundal findings. Vital
sign assessment is unnecessary unless the nurse suspects hemorrhage from
delayed involution. In a client who doesn't have a full bladder, the nurse should
evaluate lochia characteristics to detect possible hemorrhage. If the client has a full
bladder, massaging the fundus won't stimulate uterine contractions (which aid
uterine involution) or prevent uterine atony — a possible cause of hemorrhage.
A nursing assistant escorts a client in the early stages of labor to the
bathroom. When the nurse enters the client's room, she detects a strange odor
coming from the bathroom and suspects the client has been smoking
marijuana. What should the nurse do next?
1. Tell the client that smoking is prohibited in the facility, and that if she
smokes again, she'll be discharged.
2. Explain to the client that smoking poses a danger of explosion because
oxygen tanks are stored close by.
3. Notify the physician and security immediately.
4. Ask the nursing assistant to dispose of the marijuana that the client can't
smoke anymore.
Answer: 3 -The nurse should immediately notify the physician and security. The
physician must be informed because illegal drugs can interfere with the labor
,process and affect the neonate after delivery. Moreover, the client might have
consumed other illegal drugs. The nurse should also inform security who are
specially trained to handle such situations. Most hospitals prohibit smoking. The
nurse needs to alert others about the client's illegal drug use, not simply explain to
the client that smoking is prohibited. Smoking is dangerous around oxygen and it's
fine for the nurse to explain the hazard to the client; however, the nurse must first
notify the physician and security. The nursing assistant shouldn't be asked to
dispose of the marijuana.
Which of the following describes the term fetal position?
1. Relationship of the fetus's presenting part to the mother's pelvis
2. Fetal posture
3. Fetal head or breech at cervical os
4. Relationship of the fetal long axis to the mother's long axis
Answer: 1
RATIONALES: Fetal position refers to the relationship of the fetus's presenting part
to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the
part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis
to that of the mother's long axis.
At 28 weeks' gestation, a client is admitted to the labor and delivery area in
preterm labor. An I.V. infusion of ritodrine (Yutopar) is started. Which client
outcome reflects the nurse's awareness of an adverse effect of ritodrine?
1. "The client remains free from tachycardia."
2. "The client remains free from polyuria."
3. "The client remains free from hypertension."
4. "The client remains free from hyporeflexia."
Answer: 1
RATIONALES: Ritodrine and other beta-adrenergic agonists may cause tachycardia,
hypotension, bronchial dilation, increased plasma volume, increased cardiac output,
arrhythmias, myocardial ischemia, reduced urine output, restlessness, headache,
nausea, and vomiting. These drugs aren't associated with polyuria, hypertension, or
hyporeflexia.
, When caring for a client in the first stage of labor, the nurse documents
cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and
occurring about every 2 minutes. Based on these findings, the nurse should
recognize that the client is in which phase of labor?
1. Active phase
2. Latent phase
3. Descent phase
4. Transitional phase
4
In the transitional phase, the cervix dilates from 8 to 10 cm, and intense contractions
occur every 1½ to 2 minutes and last for 45 to 90 seconds. In the active phase, the
cervix dilates from 5 to 7 cm, and moderate contractions progress to strong
contractions that last 60 seconds. In the latent phase, the cervix dilates 3 to 4 cm,
and contractions are short, irregular, and mild. No descent phase exists. (Fetal
descent may begin several weeks before labor but usually doesn't occur until the
second stage of labor.)
During labor, a client asks the nurse why her blood pressure must be
measured so often. Which explanation should the nurse provide?
1. Blood pressure reflects changes in cardiovascular function, which may
affect the fetus.
2. Increased blood pressure indicates that the client is experiencing pain.
3. Increased blood pressure signals the peak of the contraction.
4. Medications given during labor affect blood pressure.
Answer: 1
RATIONALES: Frequent blood pressure measurement helps determine whether
maternal cardiovascular function is adequate. During contractions, blood flow to the
intervillous spaces changes, compromising fetal blood supply. Increased blood
pressure is expected during pain and contractions. Measuring blood pressure
frequently helps determine whether blood pressure has returned to precontraction
ANSWERS VERIFIED 100%
When assessing a client who has just delivered a neonate, the nurse finds that
the fundus is boggy and deviated to the right. What should the nurse do?
1. Have the client void.
2. Assess the client's vital signs.
3. Evaluate lochia characteristics.
4. Massage the fundus.
Answer: 1 - Having the client void can determine whether the boggy, deviated fundus
results from a full bladder — the most common cause of these fundal findings. Vital
sign assessment is unnecessary unless the nurse suspects hemorrhage from
delayed involution. In a client who doesn't have a full bladder, the nurse should
evaluate lochia characteristics to detect possible hemorrhage. If the client has a full
bladder, massaging the fundus won't stimulate uterine contractions (which aid
uterine involution) or prevent uterine atony — a possible cause of hemorrhage.
A nursing assistant escorts a client in the early stages of labor to the
bathroom. When the nurse enters the client's room, she detects a strange odor
coming from the bathroom and suspects the client has been smoking
marijuana. What should the nurse do next?
1. Tell the client that smoking is prohibited in the facility, and that if she
smokes again, she'll be discharged.
2. Explain to the client that smoking poses a danger of explosion because
oxygen tanks are stored close by.
3. Notify the physician and security immediately.
4. Ask the nursing assistant to dispose of the marijuana that the client can't
smoke anymore.
Answer: 3 -The nurse should immediately notify the physician and security. The
physician must be informed because illegal drugs can interfere with the labor
,process and affect the neonate after delivery. Moreover, the client might have
consumed other illegal drugs. The nurse should also inform security who are
specially trained to handle such situations. Most hospitals prohibit smoking. The
nurse needs to alert others about the client's illegal drug use, not simply explain to
the client that smoking is prohibited. Smoking is dangerous around oxygen and it's
fine for the nurse to explain the hazard to the client; however, the nurse must first
notify the physician and security. The nursing assistant shouldn't be asked to
dispose of the marijuana.
Which of the following describes the term fetal position?
1. Relationship of the fetus's presenting part to the mother's pelvis
2. Fetal posture
3. Fetal head or breech at cervical os
4. Relationship of the fetal long axis to the mother's long axis
Answer: 1
RATIONALES: Fetal position refers to the relationship of the fetus's presenting part
to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the
part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis
to that of the mother's long axis.
At 28 weeks' gestation, a client is admitted to the labor and delivery area in
preterm labor. An I.V. infusion of ritodrine (Yutopar) is started. Which client
outcome reflects the nurse's awareness of an adverse effect of ritodrine?
1. "The client remains free from tachycardia."
2. "The client remains free from polyuria."
3. "The client remains free from hypertension."
4. "The client remains free from hyporeflexia."
Answer: 1
RATIONALES: Ritodrine and other beta-adrenergic agonists may cause tachycardia,
hypotension, bronchial dilation, increased plasma volume, increased cardiac output,
arrhythmias, myocardial ischemia, reduced urine output, restlessness, headache,
nausea, and vomiting. These drugs aren't associated with polyuria, hypertension, or
hyporeflexia.
, When caring for a client in the first stage of labor, the nurse documents
cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and
occurring about every 2 minutes. Based on these findings, the nurse should
recognize that the client is in which phase of labor?
1. Active phase
2. Latent phase
3. Descent phase
4. Transitional phase
4
In the transitional phase, the cervix dilates from 8 to 10 cm, and intense contractions
occur every 1½ to 2 minutes and last for 45 to 90 seconds. In the active phase, the
cervix dilates from 5 to 7 cm, and moderate contractions progress to strong
contractions that last 60 seconds. In the latent phase, the cervix dilates 3 to 4 cm,
and contractions are short, irregular, and mild. No descent phase exists. (Fetal
descent may begin several weeks before labor but usually doesn't occur until the
second stage of labor.)
During labor, a client asks the nurse why her blood pressure must be
measured so often. Which explanation should the nurse provide?
1. Blood pressure reflects changes in cardiovascular function, which may
affect the fetus.
2. Increased blood pressure indicates that the client is experiencing pain.
3. Increased blood pressure signals the peak of the contraction.
4. Medications given during labor affect blood pressure.
Answer: 1
RATIONALES: Frequent blood pressure measurement helps determine whether
maternal cardiovascular function is adequate. During contractions, blood flow to the
intervillous spaces changes, compromising fetal blood supply. Increased blood
pressure is expected during pain and contractions. Measuring blood pressure
frequently helps determine whether blood pressure has returned to precontraction
