CARE FINAL STUDY GUIDE 2026 TESTED ITEMS
SOLVED
◉ The nurse assisting a laboring patient is aware that the birth of
the fetus is imminent. What is the station of the presenting part?
1. -1
2. +1
3. +3
4. +5. Answer: 4
Station is the relationship of the presenting fetal part to an
imaginary line drawn between the maternal ischial spines. The
placement of the presenting part is measured in centimeters above
or below the ischial spines. Birth is imminent when the presenting
part is at +4 to +5 cm. When the lowermost portion of the presenting
part is 1 cm above the spine, it is noted as minus (-)1. When the
presenting part is 1 cm below the spine, the station is said to be plus
(+)1. At +3, the presenting part is still descending the birth canal.
Birth is imminent when the presenting part is at +4 to +5 cm.
◉ What will the nurse mention about the effect of secondary powers
during labor to the patient?
1
,Contractions are expulsive in nature.
2
The intraabdominal pressure is decreased.
3
Contractions move downward in waves.
4
Contractions begin at pacemaker points.. Answer: 1
As soon as the presenting part of the fetus touches the pelvic floor,
the patient uses secondary powers or bearing-down efforts. This
results in contractions that are expulsive in nature. The voluntary
bearing-down efforts of the patient also result in increased
intraabdominal pressure. Primary powers signal the beginning of
labor with involuntary contractions that move downward over the
uterus in waves. These contractions begin at pacemaker points in
the thickened muscle layers of the upper uterine segment.
◉ The nurse acts as an advocate for the patient during an informed
consent. What care must the nurse take while obtaining an informed
consent? Select all that apply.
1
Check for the patient's signature.
2
Ensure that the consent is in English.
,3
Obtain a family member's signature.
4
Check for the date on the consent form.
5
Check the anesthetic care provider's signature.. Answer: 1, 4, 5
The nurse must ensure that the consent form has the correct date.
The nurse must ensure that the patient has not been compelled to
consent for the procedure. The form must carry the signature of the
anesthetic care provider, certifying that the patient has received and
expresses understanding of the explanation. The consent form must
be written or explained in the patient's primary language. The nurse
need not obtain a family member's signature on the document. The
patient's signature is important.
◉ A woman in latent labor who is positive for opiates on the urine
drug screen is complaining of severe pain. Maternal vital signs are
stable, and the fetal heart monitor displays a reassuring pattern. The
nurse's most appropriate analgesic for pain control is:
1
fentanyl (Sublimaze).
2
promethazine (Phenergan).
, 3
butorphanol tartrate (Stadol).
4
nalbuphine (Nubain). Answer: 1
Fentanyl is a commonly used opioid agonist analgesic for women in
labor. It is fast and short acting. This patient may require higher than
normal doses to achieve pain relief due to her opiate use. Phenergan
is not an analgesic. Phenergan is an ataractic (tranquilizer) that may
be used to augment the desirable effects of the opioid analgesics but
has few of those drugs' undesirable effects. Stadol is an opioid
agonist-antagonist analgesic. Its use may precipitate withdrawals in
a patient with a history of opiate use. Nubain is an opioid agonist-
antagonist analgesic. Its use may precipitate withdrawals in a
patient with a history of opiate use.
◉ The nurse is caring for a patient who is administered local
perineal infiltration anesthesia. In what situation does the nurse
expect the use of local perineal infiltration anesthesia? When a(n):
1
Episiotomy is required.
2
Forceps birth is expected.
3
Cesarean birth is expected.