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ANSWERS|LATEST!!!!2025/2026|GUARANTEED
During stage two of labor, what assessments must the labor nurse perform? (Select all that
apply.)
A. Fetal heart rate before the contraction
B. Fetal heart rate during the contraction
C. Fetal heart rate after the contraction
D. Frequency of contractions
E. Duration of contractions
F. Uterine tone between contractions - ANSWER A, B, C, D, E, F
The nurse must assess the fetal heart rate before, during and after the contractions to
determine the fetal response to the contractions. Frequency may slow during the second
stage. Duration will help facilitate decent of the presenting part. The uterine tone between
contractions should be soft to facilitate placental filling after the contraction.
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm and
occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases
with each contraction and returns to baseline after the contraction. What is the next nursing
action?
A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
1
,D. Increase the rate of the oxytocin infusion. - ANSWER D. Increase the rate of the
oxytocin infusion.
The goal of labor augmentation is to produce firm contractions that occur every 2 to 3
minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR
accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion
should be increased per protocol to stimulate the frequency and intensity of contractions.
Options A and C are indicated for fetal stress. A sterile vaginal examination places the client
at risk for infection and should be performed when the client exhibits signs of progressing
labor, which is not indicated at this time.
The nurse is teaching a prenatal class about the structure of the pelvis and is using a model
of a pelvis in the presentation. Which statements will the nurse include in the teaching plan?
(Select all that apply.)
A. "The baby has to pass through the true pelvis."
B. "The pelvis consists of three distinct features."
C. "The true pelvis is below the pelvic brim."
D. "The ischial spines determine how low the baby is located."
E. "The shape of the pelvis does not impact the labor process." - ANSWER A, B, C, D
A gynecoid shape pelvis is the most favorable for birthing. The remaining statements are
true.
A 38-week primigravida works as an office assistant and sits at a computer 8 hours each day.
She tells the nurse that her feet have begun to swell. Which instruction will aid in the
prevention of pooling of blood in the lower extremities?
A.Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
2
,D. Avoid constrictive clothing. - ANSWER C. Move about every hour.
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure
on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and
increase venous return. Option A would increase venous return from varicose veins in the
lower extremities but would be of little help with swelling. Option B might be helpful with
generalized edema but is not specific for edematous lower extremities. Option D does not
address venous return, and there is no indication in the question that constrictive clothing is
a problem.
In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close. Which
statement is accurate regarding the timing of closure of an infant's fontanels that should be
included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the
first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the
second week.
C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of
the first month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of
the second month. - ANSWER D. The anterior fontanel closes at 12 to 18 months and
the posterior fontanel by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel closes by the end of the second month. These growth and development
milestones are frequently included in questions on the licensure examination. Options A, B,
and C are incorrect.
The laboring client at term states to the nurse, "I think my water just broke." The nurse
observes a shiny, gelatinous, rope-like structure protruding from the client's vaginal area.
What is the next nursing action?
3
, A. Call for help.
B. Place the client in knee-chest position.
C. Increase the mainline IV fluids.
D. Reassure the client. - ANSWER B. Place the client in knee-chest position.
This client is showing signs of an obstetric emergency of a prolapsed umbilical cord.
Compression of the cord can lead to fetal anoxia. Placing the client in knee-chest position
reduces the weight of the presenting part off of the cord. The nurse will need to complete
the remaining options, but oxygenation of the fetus takes priority.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-term
infant who has developed localized swelling on the right side of the head. In a newborn,
what is the most likely cause of this accumulation of blood between the periosteum and
skull that does not cross the suture line?
A. Cephalohematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage - ANSWER A.
Cephalohematoma, which is caused by forceps trauma
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first
24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure
on the cranium during vaginal delivery, and is a common variation of the newborn. Options
B and D both involve intracranial bleeding and could not be detected by physical assessment
alone.
The postpartum client is preparing for discharge. She states to the nurse, "I have not had a
bowel movement yet." What are the nurse's recommendations for this client? (Select all that
apply.)
4
ANSWERS|LATEST!!!!2025/2026|GUARANTEED
During stage two of labor, what assessments must the labor nurse perform? (Select all that
apply.)
A. Fetal heart rate before the contraction
B. Fetal heart rate during the contraction
C. Fetal heart rate after the contraction
D. Frequency of contractions
E. Duration of contractions
F. Uterine tone between contractions - ANSWER A, B, C, D, E, F
The nurse must assess the fetal heart rate before, during and after the contractions to
determine the fetal response to the contractions. Frequency may slow during the second
stage. Duration will help facilitate decent of the presenting part. The uterine tone between
contractions should be soft to facilitate placental filling after the contraction.
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm and
occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases
with each contraction and returns to baseline after the contraction. What is the next nursing
action?
A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
1
,D. Increase the rate of the oxytocin infusion. - ANSWER D. Increase the rate of the
oxytocin infusion.
The goal of labor augmentation is to produce firm contractions that occur every 2 to 3
minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR
accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion
should be increased per protocol to stimulate the frequency and intensity of contractions.
Options A and C are indicated for fetal stress. A sterile vaginal examination places the client
at risk for infection and should be performed when the client exhibits signs of progressing
labor, which is not indicated at this time.
The nurse is teaching a prenatal class about the structure of the pelvis and is using a model
of a pelvis in the presentation. Which statements will the nurse include in the teaching plan?
(Select all that apply.)
A. "The baby has to pass through the true pelvis."
B. "The pelvis consists of three distinct features."
C. "The true pelvis is below the pelvic brim."
D. "The ischial spines determine how low the baby is located."
E. "The shape of the pelvis does not impact the labor process." - ANSWER A, B, C, D
A gynecoid shape pelvis is the most favorable for birthing. The remaining statements are
true.
A 38-week primigravida works as an office assistant and sits at a computer 8 hours each day.
She tells the nurse that her feet have begun to swell. Which instruction will aid in the
prevention of pooling of blood in the lower extremities?
A.Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
2
,D. Avoid constrictive clothing. - ANSWER C. Move about every hour.
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure
on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and
increase venous return. Option A would increase venous return from varicose veins in the
lower extremities but would be of little help with swelling. Option B might be helpful with
generalized edema but is not specific for edematous lower extremities. Option D does not
address venous return, and there is no indication in the question that constrictive clothing is
a problem.
In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close. Which
statement is accurate regarding the timing of closure of an infant's fontanels that should be
included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the
first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the
second week.
C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of
the first month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of
the second month. - ANSWER D. The anterior fontanel closes at 12 to 18 months and
the posterior fontanel by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel closes by the end of the second month. These growth and development
milestones are frequently included in questions on the licensure examination. Options A, B,
and C are incorrect.
The laboring client at term states to the nurse, "I think my water just broke." The nurse
observes a shiny, gelatinous, rope-like structure protruding from the client's vaginal area.
What is the next nursing action?
3
, A. Call for help.
B. Place the client in knee-chest position.
C. Increase the mainline IV fluids.
D. Reassure the client. - ANSWER B. Place the client in knee-chest position.
This client is showing signs of an obstetric emergency of a prolapsed umbilical cord.
Compression of the cord can lead to fetal anoxia. Placing the client in knee-chest position
reduces the weight of the presenting part off of the cord. The nurse will need to complete
the remaining options, but oxygenation of the fetus takes priority.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-term
infant who has developed localized swelling on the right side of the head. In a newborn,
what is the most likely cause of this accumulation of blood between the periosteum and
skull that does not cross the suture line?
A. Cephalohematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage - ANSWER A.
Cephalohematoma, which is caused by forceps trauma
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first
24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure
on the cranium during vaginal delivery, and is a common variation of the newborn. Options
B and D both involve intracranial bleeding and could not be detected by physical assessment
alone.
The postpartum client is preparing for discharge. She states to the nurse, "I have not had a
bowel movement yet." What are the nurse's recommendations for this client? (Select all that
apply.)
4
