Labor & Delivery Saunders NCLEX questions and answers
A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider
prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the
amniotomy?
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 - ans3
Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix
is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the
fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased
monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to
be monitored frequently, however.
A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse plan to
assess and document the fetal heart rate?
1.
Hourly
,2.
Every 15 minutes
3.
Every 30 minutes
4.
Before each contraction - ans2
he second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure,
and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols
recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals
for assessment in this stage of labor.
A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which
finding indicates that the rate of the infusion needs to be decreased?
1.
Increased urinary output
2.
A fetal heart rate of 180 beats/min
3.
Three contractions occurring in a 10-minute period
4.
Adequate resting tone of the uterus palpated between contractions - ans2
,A normal fetal heart rate is 120 to 160 beats/min. Acute hypoxia is a common cause of fetal tachycardia. The
dosage of oxytocin should be decreased in the presence of fetal tachycardia, which can occur from excessive
uterine activity. The goal of labor augmentation is to achieve three good-quality contractions (appropriate
intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions,
and there should be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is
transferred to the delivery room table, the nurse should place the client in which position?
1.
Supine position with a wedge under the right hip
2.
Trendelenburg's position with the legs in stirrups
3.
Prone position with the legs separated and elevated
4.
Semi-Fowler's position with a pillow under the knees - ans1
Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower
trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and
subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the
abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed
under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the
pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's
position or prone position is not practical for this type of abdominal surgery.
A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a
, breech presentation. Which intervention is least appropriate in planning the nursing care of this client?
1.
Measure fundal height.
2.
Attach electronic fetal monitoring.
3.
Prepare the client for a possible cesarean section.
4.
Visually examine the perineum and vaginal opening. - ans1
The correct option is least appropriate because fundal height should be measured at each antepartum clinic
visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment
require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal
monitoring, and any signs of distress must be reported to the health care provider. A cesarean section may be
necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of
the cord, which sometimes prolapses through the cervix.
A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is
158 beats/min and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of
moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action?
1.
Contact the obstetrician.
2.
A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider
prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the
amniotomy?
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 - ans3
Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix
is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the
fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased
monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to
be monitored frequently, however.
A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse plan to
assess and document the fetal heart rate?
1.
Hourly
,2.
Every 15 minutes
3.
Every 30 minutes
4.
Before each contraction - ans2
he second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure,
and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols
recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals
for assessment in this stage of labor.
A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which
finding indicates that the rate of the infusion needs to be decreased?
1.
Increased urinary output
2.
A fetal heart rate of 180 beats/min
3.
Three contractions occurring in a 10-minute period
4.
Adequate resting tone of the uterus palpated between contractions - ans2
,A normal fetal heart rate is 120 to 160 beats/min. Acute hypoxia is a common cause of fetal tachycardia. The
dosage of oxytocin should be decreased in the presence of fetal tachycardia, which can occur from excessive
uterine activity. The goal of labor augmentation is to achieve three good-quality contractions (appropriate
intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions,
and there should be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is
transferred to the delivery room table, the nurse should place the client in which position?
1.
Supine position with a wedge under the right hip
2.
Trendelenburg's position with the legs in stirrups
3.
Prone position with the legs separated and elevated
4.
Semi-Fowler's position with a pillow under the knees - ans1
Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower
trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and
subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the
abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed
under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the
pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's
position or prone position is not practical for this type of abdominal surgery.
A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a
, breech presentation. Which intervention is least appropriate in planning the nursing care of this client?
1.
Measure fundal height.
2.
Attach electronic fetal monitoring.
3.
Prepare the client for a possible cesarean section.
4.
Visually examine the perineum and vaginal opening. - ans1
The correct option is least appropriate because fundal height should be measured at each antepartum clinic
visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment
require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal
monitoring, and any signs of distress must be reported to the health care provider. A cesarean section may be
necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of
the cord, which sometimes prolapses through the cervix.
A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is
158 beats/min and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of
moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action?
1.
Contact the obstetrician.
2.
