Labor and Birth NCLEX Questions and Answers Already Passed Latest 2025
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is
beginning the second stage of labor? Select all that apply.
1. The contractions are regular
2. The membranes have ruptured
3. The cervix is dilated completely
4. The client begins to expel clear vaginal fluid
5. The Ferguson reflex is initiated from perineal pressure - Answers 3. The cervix is dilated completely
5. The Ferguson reflex is initiated from perineal pressure
The second stage of labor begins when the cervix is dilated completely and ends with birth of the
neonate. The woman has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options
1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse
is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most
appropriate nursing action?
1. Administer oxygen via face mask
2. Place the mother in a supine position
3. Increase the rate of the oxytocin intravenous infusion
4. Document the findings and continue to monitor the fetal patterns - Answers 1. Administer oxygen via
face mask
Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow
and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute
via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the
fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior
vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The
oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting
, from stimulation of contractions by this medication. Although the nurse would document the
occurrence, option 4 would delay necessary treatment.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks
of gestation. Which assessment finding indicates the need to contact the primary health care provider?
1. Hemoglobin of 11 g/dL
2. Fetal heart rate of 180 beats per minute
3. Maternal pulse rate of 85 beats per minute
4. White blood cell count of 12,000 - Answers 2. Fetal heart rate of 180 beats per minute
A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute
could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a
normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase
in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats
per minute over pre-pregnancy readings to facilitated increased cardiac output, oxygen transport, and
kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second
trimester and peak in the third trimester, with a normal range of 11,000-15,000.
A client arrives at a birthing center in active labor. After examination, it is determined that her
membranes are still intact and she is at a -2 station. The primary health care provider prepares to
perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the
amniotomy? Select all that apply.
1. Less pressure on her cervix
2. Decreased number of contractions
3. Increased efficiency of contractions
4. The need for increased maternal blood pressure monitoring
5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord -
Answers 3. Increased efficiency of contractions
5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is
beginning the second stage of labor? Select all that apply.
1. The contractions are regular
2. The membranes have ruptured
3. The cervix is dilated completely
4. The client begins to expel clear vaginal fluid
5. The Ferguson reflex is initiated from perineal pressure - Answers 3. The cervix is dilated completely
5. The Ferguson reflex is initiated from perineal pressure
The second stage of labor begins when the cervix is dilated completely and ends with birth of the
neonate. The woman has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options
1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse
is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most
appropriate nursing action?
1. Administer oxygen via face mask
2. Place the mother in a supine position
3. Increase the rate of the oxytocin intravenous infusion
4. Document the findings and continue to monitor the fetal patterns - Answers 1. Administer oxygen via
face mask
Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow
and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute
via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the
fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior
vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The
oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting
, from stimulation of contractions by this medication. Although the nurse would document the
occurrence, option 4 would delay necessary treatment.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks
of gestation. Which assessment finding indicates the need to contact the primary health care provider?
1. Hemoglobin of 11 g/dL
2. Fetal heart rate of 180 beats per minute
3. Maternal pulse rate of 85 beats per minute
4. White blood cell count of 12,000 - Answers 2. Fetal heart rate of 180 beats per minute
A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute
could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a
normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase
in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats
per minute over pre-pregnancy readings to facilitated increased cardiac output, oxygen transport, and
kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second
trimester and peak in the third trimester, with a normal range of 11,000-15,000.
A client arrives at a birthing center in active labor. After examination, it is determined that her
membranes are still intact and she is at a -2 station. The primary health care provider prepares to
perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the
amniotomy? Select all that apply.
1. Less pressure on her cervix
2. Decreased number of contractions
3. Increased efficiency of contractions
4. The need for increased maternal blood pressure monitoring
5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord -
Answers 3. Increased efficiency of contractions
5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
