LABOR AND BIRTH NCLEX EXAM
QUESTIONS AND ANSWERS
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 - ANS 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
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, 3. Increase the rate of the oxytocin intravenous infusion
4. Document the findings and continue to monitor the fetal patterns - ANS 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 - ANS 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.
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QUESTIONS AND ANSWERS
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 - ANS 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
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 1
, 3. Increase the rate of the oxytocin intravenous infusion
4. Document the findings and continue to monitor the fetal patterns - ANS 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 - ANS 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.
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