Labor And Delivery -Questions & Correct Answers
The nurse is caring for a client with gestational diabetes mellitus during the
second stage of labor. After birth of the head, the nurse notes retraction of the
fetal head against the maternal perineum. Which action should the nurse
anticipate? ✔️Ans - Pressing downward on the symphysis pubis - Shoulder
dystocia occurs when the fetal head emerges but the anterior shoulder
remains wedged behind the maternal symphysis pubis.
The nurse should be prepared to perform McRoberts maneuver and apply
suprapubic pressure.
What is the McRobert's maneuver? ✔️Ans - Used to manage shoulder
dystocia during delivery of the infant. Maternal legs are removed from
stirrups and sharply flexed upon the abdomen.
A client at 41 weeks gestation is admitted to the labor and delivery unit for
labor induction. The nurse is assisting the health care provider with an
amniotomy. What actions should the nurse anticipate? ✔️Ans - 1)
Assessing fetal HR before and after procedure
2) Checking client's temp Q2H3) Noting characteristics of amniotic fluid 17,
30,
- When assisting with an amniotomy, the nurse should assess the fetal heart
rate, note the characteristics of the amniotic fluid, and assist the client to an
upright position after the procedure.
A client in active labor who received an epidural 20 minutes ago reports
feeling nauseated and lightheaded.
Which action should the nurse perform first? ✔️Ans - Obtain BP - Epidural
blocks can inhibit the sympathetic nervous system, causing peripheral
vasodilation leading to hypotension.
Hypotensive symptoms include lightheadedness and nausea.
The nurse should first assess blood pressure and then intervene (eg, IV fluids,
left lateral positioning, oxygen) as appropriate.
A pregnant client admitted for induction of labor is receiving an oxytocin
infusion. The baseline fetal heart rate is 140/min and the strip is shown in the
, exhibit. What is the nurse's best course of action? ✔️Ans - Continue to
monitor the client
- An acceleration is a reassuring finding most often indicating fetal movement.
Moderate variability is considered "good" and "normal" and fluctuates off
baseline from 6-25/min.
- An acceleration of the fetal heart rate of at least 15/min above the baseline
lasting for at least 15 seconds is a reassuring finding most often indicating
fetal movement.
A client in labor with a history of a previous cesarean birth has chosen to
attempt a vaginal birth. During labor, which finding would be most concerning
to the nurse? ✔️Ans - Cessation of contractions and tachycardia
- This is uterine rupture
What are signs of uterine rupture? ✔️Ans - Signs of uterine rupture may
include:
- abnormal fetal heart rate pattern (ie, decelerations, decreased variability,
bradycardia),
- loss of fetal station, constant abdominal pain, cessation of uterine
contractions, and maternal tachycardia
What signs are indicative of a normal contraction pattern? ✔️Ans - -Strong
contractions every 3-4 minutes are probably indicative of a normal labor
contraction pattern.
-The contraction duration should not exceed 90 seconds or occur less than 2
minutes apart.
A nurse is preparing to administer oxytocin to induce labor in a pregnant
client at term gestation. Which of the following nursing actions are
appropriate during oxytocin infusion? ✔️Ans - 1) Assess the uterine
contraction pattern
2) Initiate continuous FHR monitoring
3) Place IV oxytocin on an electric infusion pump
- Oxytocin is a high-alert medication requiring precise administration via a
secondary IV line on an electronic infusion pump and frequent maternal/fetal
assessment.
The nurse is caring for a client with gestational diabetes mellitus during the
second stage of labor. After birth of the head, the nurse notes retraction of the
fetal head against the maternal perineum. Which action should the nurse
anticipate? ✔️Ans - Pressing downward on the symphysis pubis - Shoulder
dystocia occurs when the fetal head emerges but the anterior shoulder
remains wedged behind the maternal symphysis pubis.
The nurse should be prepared to perform McRoberts maneuver and apply
suprapubic pressure.
What is the McRobert's maneuver? ✔️Ans - Used to manage shoulder
dystocia during delivery of the infant. Maternal legs are removed from
stirrups and sharply flexed upon the abdomen.
A client at 41 weeks gestation is admitted to the labor and delivery unit for
labor induction. The nurse is assisting the health care provider with an
amniotomy. What actions should the nurse anticipate? ✔️Ans - 1)
Assessing fetal HR before and after procedure
2) Checking client's temp Q2H3) Noting characteristics of amniotic fluid 17,
30,
- When assisting with an amniotomy, the nurse should assess the fetal heart
rate, note the characteristics of the amniotic fluid, and assist the client to an
upright position after the procedure.
A client in active labor who received an epidural 20 minutes ago reports
feeling nauseated and lightheaded.
Which action should the nurse perform first? ✔️Ans - Obtain BP - Epidural
blocks can inhibit the sympathetic nervous system, causing peripheral
vasodilation leading to hypotension.
Hypotensive symptoms include lightheadedness and nausea.
The nurse should first assess blood pressure and then intervene (eg, IV fluids,
left lateral positioning, oxygen) as appropriate.
A pregnant client admitted for induction of labor is receiving an oxytocin
infusion. The baseline fetal heart rate is 140/min and the strip is shown in the
, exhibit. What is the nurse's best course of action? ✔️Ans - Continue to
monitor the client
- An acceleration is a reassuring finding most often indicating fetal movement.
Moderate variability is considered "good" and "normal" and fluctuates off
baseline from 6-25/min.
- An acceleration of the fetal heart rate of at least 15/min above the baseline
lasting for at least 15 seconds is a reassuring finding most often indicating
fetal movement.
A client in labor with a history of a previous cesarean birth has chosen to
attempt a vaginal birth. During labor, which finding would be most concerning
to the nurse? ✔️Ans - Cessation of contractions and tachycardia
- This is uterine rupture
What are signs of uterine rupture? ✔️Ans - Signs of uterine rupture may
include:
- abnormal fetal heart rate pattern (ie, decelerations, decreased variability,
bradycardia),
- loss of fetal station, constant abdominal pain, cessation of uterine
contractions, and maternal tachycardia
What signs are indicative of a normal contraction pattern? ✔️Ans - -Strong
contractions every 3-4 minutes are probably indicative of a normal labor
contraction pattern.
-The contraction duration should not exceed 90 seconds or occur less than 2
minutes apart.
A nurse is preparing to administer oxytocin to induce labor in a pregnant
client at term gestation. Which of the following nursing actions are
appropriate during oxytocin infusion? ✔️Ans - 1) Assess the uterine
contraction pattern
2) Initiate continuous FHR monitoring
3) Place IV oxytocin on an electric infusion pump
- Oxytocin is a high-alert medication requiring precise administration via a
secondary IV line on an electronic infusion pump and frequent maternal/fetal
assessment.
