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Labor & Delivery Questions and Answers
(Expert Solutions)
Q: A nurse assesses a client during the third stage of labor. Which assessment findings
indicate that the client is experiencing postpartum hemorrhage?, 🗹🗹: Heart rate
120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg
Q: A client in the first stage of labor is being monitored using an external fetal monitor.
A nurse notes variable decelerations on the monitoring strip. Into what position should
the nurse assist the client?, 🗹🗹: lateral
Q: A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP)
syndrome is admitted to the labor and delivery unit. The client's condition rapidly
deteriorates and despite efforts by the staff, the client dies. After the client's death, the
nursing staff displays many emotions. Who should the nurse manager consult to help the
staff cope with this unexpected death?
1. The human resource director, so she can arrange vacation time for the staff
2. The physician, so he can provide education about HELLP syndrome
3. The social worker, so she can contact the family about funeral arrangements and pass
along the information to the nursing staff
4. The chaplain, because his educational background includes strategies for handling
grief, 🗹🗹: Answer: 4
RATIONALES: The chaplain should be consulted because his educational background
provides strategies for helping others handle grief. Providing the staff with vacation
isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The
staff needs grief counseling, not education about HELLP syndrome. Asking the social
worker to contact the family about the funeral arrangements isn't appropriate.
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Q: Two clients arrive at the labor and delivery triage area at the same time. The first
client states that her water has been leaking, but that she hasn't had any contractions.
The second client says she's having 1-minute contractions every 3 minutes and that she
feels like pushing. How should a nurse prioritize these clients?, 🗹🗹: The nurse
should assign priority to the second client. Her signs and symptoms indicate that her
baby's birth is imminent.
Q: A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm
dilated, and she is starting to feel considerable discomfort during contractions. The nurse
should instruct the client to change from slow chest breathing to which breathing
technique?
a) deep chest breathing
b) rapid pant-blow breathing
c) slow abdominal breathing
d) rapid, shallow chest breathing, 🗹🗹: Rapid, shallow chest breathing
The psychoprophylaxis method of childbirth suggests using slow chest breathing until it
becomes ineffective during labor contractions, then switching to shallow chest
breathing (mostly at the sternum) during the peak of a contraction. The rate is 50 to 70
breaths/min.
Deep chest breathing is appropriate for the early phase of labor, in which the client
exhibits less frequent contractions.
When transition nears, a rapid pant-blow pattern of breathing is used.
Slow abdominal breathing is very difficult for clients in labor.
Q: While a 31-year-old multigravida at 39 weeks' gestation in active labor is being
admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm
dilated and the presenting part is at 0 station. Which of the following should the nurse do
first?
a) Prepare the client for imminent birth.
b) Note the color, amount, and odor of the amniotic fluid.
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c) Auscultate the client's blood pressure.
d) Perform a vaginal examination to determine dilation., 🗹🗹: Note the color,
amount, and odor of the amniotic fluid.
Q: The primary health care provider orders an amniocentesis for a primigravid client at
35 weeks' gestation in early labor to determine fetal lung maturity. Which of the
following is an indicator of fetal lung maturity?, 🗹🗹: Lecithin-sphingomyelin (L/S
ratio).
Q: A multigravid client is admitted at 4-cm dilation and is requesting pain medication.
The nurse gives the client nalbuphine 15 mg. Within five minutes, the client tells the
nurse she feels like she needs to have a bowel movement. The nurse should first:
prepare for birth. complete a vaginal examination to determine dilation, effacement,
and station. have naloxone hydrochloride available in the birthing room. document the
client's relief due to pain medication., 🗹🗹: Complete a vaginal examination to
determine dilation, effacement, and station
Q: The health care provider (HCP) plans to perform an amniotomy on a multiparous
client admitted to the labor area at 41 weeks' gestation for labor induction. After the
amniotomy, the nurse should first:
assess the client's temperature and pulse. document the color of the amniotic fluid.
monitor the client's contraction pattern. assess the fetal heart rate (FHR) for 1 full
minute., 🗹🗹: assess the fetal heart rate (FHR) for 1 full minute.
Q: The nurse has provided an in-service presentation to ancillary staff about standard
precautions on the birthing unit. The nurse determines that one of the staff members
needs further instructions when the nurse makes which observation?
a) placement of bloody sheets in a container designated for contaminated linens
b) use of protective goggles during a cesarean birth
c) disposal of used scalpel blades in a puncture-resistant container
Labor & Delivery Questions and Answers
(Expert Solutions)
Q: A nurse assesses a client during the third stage of labor. Which assessment findings
indicate that the client is experiencing postpartum hemorrhage?, 🗹🗹: Heart rate
120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg
Q: A client in the first stage of labor is being monitored using an external fetal monitor.
A nurse notes variable decelerations on the monitoring strip. Into what position should
the nurse assist the client?, 🗹🗹: lateral
Q: A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP)
syndrome is admitted to the labor and delivery unit. The client's condition rapidly
deteriorates and despite efforts by the staff, the client dies. After the client's death, the
nursing staff displays many emotions. Who should the nurse manager consult to help the
staff cope with this unexpected death?
1. The human resource director, so she can arrange vacation time for the staff
2. The physician, so he can provide education about HELLP syndrome
3. The social worker, so she can contact the family about funeral arrangements and pass
along the information to the nursing staff
4. The chaplain, because his educational background includes strategies for handling
grief, 🗹🗹: Answer: 4
RATIONALES: The chaplain should be consulted because his educational background
provides strategies for helping others handle grief. Providing the staff with vacation
isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The
staff needs grief counseling, not education about HELLP syndrome. Asking the social
worker to contact the family about the funeral arrangements isn't appropriate.
, Page | 2
Q: Two clients arrive at the labor and delivery triage area at the same time. The first
client states that her water has been leaking, but that she hasn't had any contractions.
The second client says she's having 1-minute contractions every 3 minutes and that she
feels like pushing. How should a nurse prioritize these clients?, 🗹🗹: The nurse
should assign priority to the second client. Her signs and symptoms indicate that her
baby's birth is imminent.
Q: A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm
dilated, and she is starting to feel considerable discomfort during contractions. The nurse
should instruct the client to change from slow chest breathing to which breathing
technique?
a) deep chest breathing
b) rapid pant-blow breathing
c) slow abdominal breathing
d) rapid, shallow chest breathing, 🗹🗹: Rapid, shallow chest breathing
The psychoprophylaxis method of childbirth suggests using slow chest breathing until it
becomes ineffective during labor contractions, then switching to shallow chest
breathing (mostly at the sternum) during the peak of a contraction. The rate is 50 to 70
breaths/min.
Deep chest breathing is appropriate for the early phase of labor, in which the client
exhibits less frequent contractions.
When transition nears, a rapid pant-blow pattern of breathing is used.
Slow abdominal breathing is very difficult for clients in labor.
Q: While a 31-year-old multigravida at 39 weeks' gestation in active labor is being
admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm
dilated and the presenting part is at 0 station. Which of the following should the nurse do
first?
a) Prepare the client for imminent birth.
b) Note the color, amount, and odor of the amniotic fluid.
, Page | 3
c) Auscultate the client's blood pressure.
d) Perform a vaginal examination to determine dilation., 🗹🗹: Note the color,
amount, and odor of the amniotic fluid.
Q: The primary health care provider orders an amniocentesis for a primigravid client at
35 weeks' gestation in early labor to determine fetal lung maturity. Which of the
following is an indicator of fetal lung maturity?, 🗹🗹: Lecithin-sphingomyelin (L/S
ratio).
Q: A multigravid client is admitted at 4-cm dilation and is requesting pain medication.
The nurse gives the client nalbuphine 15 mg. Within five minutes, the client tells the
nurse she feels like she needs to have a bowel movement. The nurse should first:
prepare for birth. complete a vaginal examination to determine dilation, effacement,
and station. have naloxone hydrochloride available in the birthing room. document the
client's relief due to pain medication., 🗹🗹: Complete a vaginal examination to
determine dilation, effacement, and station
Q: The health care provider (HCP) plans to perform an amniotomy on a multiparous
client admitted to the labor area at 41 weeks' gestation for labor induction. After the
amniotomy, the nurse should first:
assess the client's temperature and pulse. document the color of the amniotic fluid.
monitor the client's contraction pattern. assess the fetal heart rate (FHR) for 1 full
minute., 🗹🗹: assess the fetal heart rate (FHR) for 1 full minute.
Q: The nurse has provided an in-service presentation to ancillary staff about standard
precautions on the birthing unit. The nurse determines that one of the staff members
needs further instructions when the nurse makes which observation?
a) placement of bloody sheets in a container designated for contaminated linens
b) use of protective goggles during a cesarean birth
c) disposal of used scalpel blades in a puncture-resistant container
