NURS 316L | NURS316L Exam 2: OB Clinical - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client in the active phase of the first stage of labor. Which cervical
dilation measurement should the nurse expect to document?
A. 1 to 3 cm
B. 11 to 13 cm
C. 6 to 10 cm
D. 0 cm
Correct Answer: C
Rationale: The active phase of the first stage of labor is now defined as starting at 6 cm and
continuing until 10 cm. During this phase, the rate of cervical change increases significantly
compared to the latent phase. Nursing care focuses on pain management and frequent
monitoring of the mother and fetus. The latent phase covers 0 to 5 cm according to updated
clinical guidelines. Precise documentation of these stages helps the medical team track the
progression of labor effectively.
2. While observing the fetal heart rate (FHR) monitor, the nurse identifies late decelerations.
Which of the following is the priority nursing action?
A. Increase the oxytocin infusion rate.
B. Assist the client into a side-lying position.
C. Prepare the client for a cesarean section immediately.
D. Perform a vaginal exam to check for cord prolapse.
Correct Answer: B
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. Repositioning the mother to a side-lying
position is the first step to alleviate pressure on the vena cava. This simple maneuver can
significantly improve blood flow to the placenta and the fetus. The nurse should also
consider administering oxygen and increasing the IV fluid bolus. Documentation of the FHR
response to these interventions is essential for clinical management.
3. The nurse notes variable decelerations on the fetal monitor. What is the most likely cause
of this pattern?
A. Uteroplacental insufficiency
B. Fetal head compression
,C. Umbilical cord compression
D. Maternal fever or infection
Correct Answer: C
Rationale: Variable decelerations are typically characterized by an abrupt decrease and
return to the baseline FHR. These patterns are most commonly caused by umbilical cord
compression during contractions or fetal movement. The nurse should assess the patient
and attempt to change her position to relieve the pressure. Unlike late decelerations,
variables are often shaped like a V, U, or W. Constant monitoring is required to ensure the
fetus is tolerating these changes without distress.
4. During the fourth stage of labor, which assessment finding is the most critical for the nurse
to report?
A. Maternal heart rate of 90 beats per minute
B. A boggy uterus that does not firm up after massage
C. Moderate amount of lochia rubra
D. Complaints of thirst and fatigue
Correct Answer: B
Rationale: The fourth stage of labor is the first 1 to 2 hours after the delivery of the
placenta. A boggy uterus indicates uterine atony, which is the primary cause of postpartum
hemorrhage. The nurse must perform fundal massage immediately to stimulate uterine
contractions. If the uterus remains boggy, the healthcare provider must be notified to order
uterotonic medications. Monitoring vital signs and bleeding is the priority during this
recovery period.
5. A client has just received an epidural for pain management. Which vital sign must the
nurse monitor most closely for the next 15-30 minutes?
A. Oxygen saturation
B. Temperature
C. Respiratory rate
D. Blood pressure
Correct Answer: D
Rationale: Epidural anesthesia often causes maternal hypotension due to the blockade of
the sympathetic nervous system. This drop in blood pressure can reduce placental
perfusion and lead to fetal heart rate decelerations. The nurse must assess blood pressure
every few minutes immediately following the procedure. To mitigate this risk, a fluid bolus
is typically administered before the epidural starts. If hypotension occurs, the nurse may
need to administer ephedrine as ordered.
, 6. The nurse observes that the fetus is at +2 station. This means that the presenting part is:
A. 2 cm above the ischial spines
B. Floating above the pelvic inlet
C. 2 cm below the ischial spines
D. At the level of the ischial spines
Correct Answer: C
Rationale: Station is a measurement of the progress of descent in relation to the maternal
ischial spines. A station of 0 indicates that the presenting part is level with the spines.
Positive numbers indicate that the baby has descended below the spines toward the
vaginal opening. A +2 station means the baby’s head is 2 cm below the level of the spines.
This assessment helps the nurse determine the proximity of delivery.
7. A nurse is performing Leopold maneuvers. What is the primary purpose of this
assessment?
A. To estimate the amount of amniotic fluid
B. To assess for uterine contractions
C. To determine fetal position and presentation
D. To measure the cervical dilation and effacement
Correct Answer: C
Rationale: Leopold maneuvers consist of four distinct palpations of the pregnant
abdomen. These maneuvers allow the nurse to identify the fetal lie, presentation, and
position. Knowing where the fetal back is located helps the nurse find the best place to
listen for fetal heart tones. This non-invasive assessment is typically done prior to placing
external monitors. It provides valuable information for planning the delivery process.
8. Which clinical sign indicates that the third stage of labor is complete?
A. The birth of the baby
B. The mother begins pushing
C. The cervix is fully dilated to 10 cm
D. The delivery of the placenta
Correct Answer: D
Rationale: The third stage of labor begins immediately after the infant is born. This stage
concludes once the placenta and membranes are entirely delivered. During this time, the
nurse monitors for signs of placental separation like a lengthening cord and a gush of
blood. It usually lasts between 5 to 30 minutes. Ensuring the placenta is intact is vital to
prevent late postpartum hemorrhage.
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client in the active phase of the first stage of labor. Which cervical
dilation measurement should the nurse expect to document?
A. 1 to 3 cm
B. 11 to 13 cm
C. 6 to 10 cm
D. 0 cm
Correct Answer: C
Rationale: The active phase of the first stage of labor is now defined as starting at 6 cm and
continuing until 10 cm. During this phase, the rate of cervical change increases significantly
compared to the latent phase. Nursing care focuses on pain management and frequent
monitoring of the mother and fetus. The latent phase covers 0 to 5 cm according to updated
clinical guidelines. Precise documentation of these stages helps the medical team track the
progression of labor effectively.
2. While observing the fetal heart rate (FHR) monitor, the nurse identifies late decelerations.
Which of the following is the priority nursing action?
A. Increase the oxytocin infusion rate.
B. Assist the client into a side-lying position.
C. Prepare the client for a cesarean section immediately.
D. Perform a vaginal exam to check for cord prolapse.
Correct Answer: B
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. Repositioning the mother to a side-lying
position is the first step to alleviate pressure on the vena cava. This simple maneuver can
significantly improve blood flow to the placenta and the fetus. The nurse should also
consider administering oxygen and increasing the IV fluid bolus. Documentation of the FHR
response to these interventions is essential for clinical management.
3. The nurse notes variable decelerations on the fetal monitor. What is the most likely cause
of this pattern?
A. Uteroplacental insufficiency
B. Fetal head compression
,C. Umbilical cord compression
D. Maternal fever or infection
Correct Answer: C
Rationale: Variable decelerations are typically characterized by an abrupt decrease and
return to the baseline FHR. These patterns are most commonly caused by umbilical cord
compression during contractions or fetal movement. The nurse should assess the patient
and attempt to change her position to relieve the pressure. Unlike late decelerations,
variables are often shaped like a V, U, or W. Constant monitoring is required to ensure the
fetus is tolerating these changes without distress.
4. During the fourth stage of labor, which assessment finding is the most critical for the nurse
to report?
A. Maternal heart rate of 90 beats per minute
B. A boggy uterus that does not firm up after massage
C. Moderate amount of lochia rubra
D. Complaints of thirst and fatigue
Correct Answer: B
Rationale: The fourth stage of labor is the first 1 to 2 hours after the delivery of the
placenta. A boggy uterus indicates uterine atony, which is the primary cause of postpartum
hemorrhage. The nurse must perform fundal massage immediately to stimulate uterine
contractions. If the uterus remains boggy, the healthcare provider must be notified to order
uterotonic medications. Monitoring vital signs and bleeding is the priority during this
recovery period.
5. A client has just received an epidural for pain management. Which vital sign must the
nurse monitor most closely for the next 15-30 minutes?
A. Oxygen saturation
B. Temperature
C. Respiratory rate
D. Blood pressure
Correct Answer: D
Rationale: Epidural anesthesia often causes maternal hypotension due to the blockade of
the sympathetic nervous system. This drop in blood pressure can reduce placental
perfusion and lead to fetal heart rate decelerations. The nurse must assess blood pressure
every few minutes immediately following the procedure. To mitigate this risk, a fluid bolus
is typically administered before the epidural starts. If hypotension occurs, the nurse may
need to administer ephedrine as ordered.
, 6. The nurse observes that the fetus is at +2 station. This means that the presenting part is:
A. 2 cm above the ischial spines
B. Floating above the pelvic inlet
C. 2 cm below the ischial spines
D. At the level of the ischial spines
Correct Answer: C
Rationale: Station is a measurement of the progress of descent in relation to the maternal
ischial spines. A station of 0 indicates that the presenting part is level with the spines.
Positive numbers indicate that the baby has descended below the spines toward the
vaginal opening. A +2 station means the baby’s head is 2 cm below the level of the spines.
This assessment helps the nurse determine the proximity of delivery.
7. A nurse is performing Leopold maneuvers. What is the primary purpose of this
assessment?
A. To estimate the amount of amniotic fluid
B. To assess for uterine contractions
C. To determine fetal position and presentation
D. To measure the cervical dilation and effacement
Correct Answer: C
Rationale: Leopold maneuvers consist of four distinct palpations of the pregnant
abdomen. These maneuvers allow the nurse to identify the fetal lie, presentation, and
position. Knowing where the fetal back is located helps the nurse find the best place to
listen for fetal heart tones. This non-invasive assessment is typically done prior to placing
external monitors. It provides valuable information for planning the delivery process.
8. Which clinical sign indicates that the third stage of labor is complete?
A. The birth of the baby
B. The mother begins pushing
C. The cervix is fully dilated to 10 cm
D. The delivery of the placenta
Correct Answer: D
Rationale: The third stage of labor begins immediately after the infant is born. This stage
concludes once the placenta and membranes are entirely delivered. During this time, the
nurse monitors for signs of placental separation like a lengthening cord and a gush of
blood. It usually lasts between 5 to 30 minutes. Ensuring the placenta is intact is vital to
prevent late postpartum hemorrhage.
