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“LABOR & DELIVERY SAUNDERS NCLEX
QUESTIONS 80QW/EXP, NAXLEX 2026 ”LATEST
EXAM 2026 – 2027 SOLVED QUESTIONS &
ANSWERS VERIFIED 100% GRADED A+ (LATEST
VERSION) WELL REVISED 100% GUARANTEE
PASS
don't miss any practice revision materials contact me +254111429458
Labor & Delivery Saunders NCLEX questions 80Qw/exp, Naxlex, Update 26, HESI
Remediation Packet Maternity, maternity hesi questions, Mark Klimek -
Congenital Heart Defects, Maternity HESI Test bank (combined red hesi and other
sources)
The nurse prepares a plan of care for the client with preeclampsia and
documents that if the client progresses from preeclampsia to eclampsia, the
nurse should take which first action?Position the client on their side and
ensure airway patency. This prevents aspiration and promotes adequate
oxygenation.
2. Administer oxygen after securing the airway to optimize oxygen delivery.
3. Administer magnesium sulfate to prevent further seizures.
4. Assess blood pressure and fetal heart rate after stabilizing the client.
These assessments are important, but ensuring the safety of the client
through airway management comes first.
Position the client on their side and ensure airway patency.
, Page 2 of 103
The admission assessment and would suspect a diagnosis of placenta
previa(low lying) if which. A prenatal client with vaginal bleeding is being
admitted to the labor unit. The labor room nurse is performing the finding is
noted?
Painless vaginal bleeding
A prenatal client with severe abdominal pain is admitted to the maternity unit.
The nurse is monitoring the client closely because concealed bleeding is
suspected. Which assessment finding would indicate the presence of
concealed bleeding?Rationale:
Concealed bleeding typically occurs in conditions like placental
abruption?planceta seperation, where the placenta detaches prematurely from
the uterine wall. In cases of concealed bleeding, blood accumulates behind the
placenta, which can cause an increase in fundal height as the blood collection
distends the uterus.
Increase in fundal height
The nurse is caring for a client during the second stage of labor. On
assessment, the nurse notes a slowing of the fetal heart rate and a loss of
variability. Which is the initial nursing action?
*Slowing fetal heart rate and loss of variability suggest fetal distress. The
initial action is to improve maternal oxygenation and placental blood flow by
turning the client onto her side and administering oxygen via face mask at 8 to
10 L/min. This helps relieve pressure on the vena cava and increases oxygen
supply to the fetus.
Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.
An amniotomy(water breaking/Artificial rupture of membranes/arom),is
performed on a client in labor. On the amniotic fluid examination, the delivery
room nurse would identify which findings as normal?Rationale:Normal
amniotic fluid is usually pale straw-colored and may contain flecks of
vernix (the protective covering on the fetus's skin). The fluid should
be odorless.
Pale straw-colored, with flecks of vernix
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
, Page 3 of 103
moderate intensity. On the basis of these assessment findings, what is the
appropriate nursing action?
RationaleThe fetal heart rate of 158 beats/min is within the normal range
(typically 110-160 beats/min), and the contractions are occurring at a regular
interval with moderate intensity and a reasonable duration. These findings
suggest that the labor is progressing normally, and there is no immediate
concern.
Continue to monitor the client.
The nurse is developing a plan of care for a pregnant client with a diagnosis of
severe preeclampsia. Which nursing actions should be included in the care
plan for this client? SATA.
Keep the room semi-dark.Initiate seizure precautions.Pad the side rails of the
bed.Avoid environmental stimulation.
The labor room nurse assists with the administration of a lumbar epidural
block. How should the nurse check for the major side effect associated with
this type of regional anesthesia?
*A major side effect of a lumbar epidural block is hypotension due to
vasodilation and reduced venous return. Blood pressure should be monitored
frequently, initially every 1-2 minutes for 15 minutes, then every 10-15 minutes.
Reflexes, temperature, and apical pulse are not specific to this anesthesia.
Monitoring the mother's blood pressure
After an amniotomy(WATER BREAKING), the nurse immediately assesses the
fetal heart rate for at least 1 minute to detect changes associated with prolapse
or compression of the umbilical cord. The nurse also notes the quantity, color,
and odor of the amniotic fluid. Which of the following actions should the nurse
prioritize next?
Continue to monitor the fetal heart rate and document findings.
The goal for a woman with partial premature separation of the
placenta/ABRUPTIO PLACENTTAE is, "The woman will not exhibit signs of
fetal distress." Which outcome, documented by the nurse, would indicate that
this goal has been achieved?
Rationale:The fetal heart rate (FHR) reflects fetal well-being, indicating that the
fetus is responding appropriately to labor stress. In cases of partial premature
separation of the placenta, a stable FHR suggests the fetus is not in distress.
, Page 4 of 103
Short-term variability present
The nurse is administering magnesium sulfate to a client for preeclampsia(
HYPERTENSIVE) at 34 weeks gestation. What is the priority nursing action for
this client?
Schedule a non-stress test every 4 hours to assess fetal well-being.
The nurse is caring for a client in active labor. Which nursing intervention
would be the best method to prevent fetal heart rate decelerations?
Encourage an upright or side-lying maternal position.
The nurse is preparing to administer an analgesic to a client in labor. Which
analgesic is contraindicated for a client who has a history of opioid
dependency?
Rationale:
Butorphanol tartrate is a mixed agonist-antagonist opioid analgesic.
It contraindicated for clients with a history of opioid dependency because it
can trigger withdrawal symptoms.This occurs due to its antagonistic
properties on opioid receptors, leading to withdrawal symptoms in opioid-
dependent clients.
Butorphanol tartrate(relieve pain/opioid)
The nurse in a delivery room is assessing a client immediately after delivery of
the placenta. Which maternal observation could indicate uterine
inversion(inside/out) and require immediate intervention?
A soft and boggy uterus(uterine atony)
The nurse is caring for a client in the transition phase of the first stage of
labor. The client is experiencing uterine contractions every 2 minutes and she
cries out in pain with each contraction. What is the nurse's best interpretation
of this client's behavior?
Fear of losing control
A pregnant client is admitted in labor. The nursing assessment reveals that the
client's hemoglobin and hematocrit levels are low, indicating anemia. What
should the nurse observe for throughout the client's labor?
Rationale: Anemia during labor increases the risk of postpartum hemorrhage.
The nurse should monitor for excessive bleeding or difficulty controlling
bleeding after delivery.
Hemorrhage(heavy bleeding)
“LABOR & DELIVERY SAUNDERS NCLEX
QUESTIONS 80QW/EXP, NAXLEX 2026 ”LATEST
EXAM 2026 – 2027 SOLVED QUESTIONS &
ANSWERS VERIFIED 100% GRADED A+ (LATEST
VERSION) WELL REVISED 100% GUARANTEE
PASS
don't miss any practice revision materials contact me +254111429458
Labor & Delivery Saunders NCLEX questions 80Qw/exp, Naxlex, Update 26, HESI
Remediation Packet Maternity, maternity hesi questions, Mark Klimek -
Congenital Heart Defects, Maternity HESI Test bank (combined red hesi and other
sources)
The nurse prepares a plan of care for the client with preeclampsia and
documents that if the client progresses from preeclampsia to eclampsia, the
nurse should take which first action?Position the client on their side and
ensure airway patency. This prevents aspiration and promotes adequate
oxygenation.
2. Administer oxygen after securing the airway to optimize oxygen delivery.
3. Administer magnesium sulfate to prevent further seizures.
4. Assess blood pressure and fetal heart rate after stabilizing the client.
These assessments are important, but ensuring the safety of the client
through airway management comes first.
Position the client on their side and ensure airway patency.
, Page 2 of 103
The admission assessment and would suspect a diagnosis of placenta
previa(low lying) if which. A prenatal client with vaginal bleeding is being
admitted to the labor unit. The labor room nurse is performing the finding is
noted?
Painless vaginal bleeding
A prenatal client with severe abdominal pain is admitted to the maternity unit.
The nurse is monitoring the client closely because concealed bleeding is
suspected. Which assessment finding would indicate the presence of
concealed bleeding?Rationale:
Concealed bleeding typically occurs in conditions like placental
abruption?planceta seperation, where the placenta detaches prematurely from
the uterine wall. In cases of concealed bleeding, blood accumulates behind the
placenta, which can cause an increase in fundal height as the blood collection
distends the uterus.
Increase in fundal height
The nurse is caring for a client during the second stage of labor. On
assessment, the nurse notes a slowing of the fetal heart rate and a loss of
variability. Which is the initial nursing action?
*Slowing fetal heart rate and loss of variability suggest fetal distress. The
initial action is to improve maternal oxygenation and placental blood flow by
turning the client onto her side and administering oxygen via face mask at 8 to
10 L/min. This helps relieve pressure on the vena cava and increases oxygen
supply to the fetus.
Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.
An amniotomy(water breaking/Artificial rupture of membranes/arom),is
performed on a client in labor. On the amniotic fluid examination, the delivery
room nurse would identify which findings as normal?Rationale:Normal
amniotic fluid is usually pale straw-colored and may contain flecks of
vernix (the protective covering on the fetus's skin). The fluid should
be odorless.
Pale straw-colored, with flecks of vernix
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
, Page 3 of 103
moderate intensity. On the basis of these assessment findings, what is the
appropriate nursing action?
RationaleThe fetal heart rate of 158 beats/min is within the normal range
(typically 110-160 beats/min), and the contractions are occurring at a regular
interval with moderate intensity and a reasonable duration. These findings
suggest that the labor is progressing normally, and there is no immediate
concern.
Continue to monitor the client.
The nurse is developing a plan of care for a pregnant client with a diagnosis of
severe preeclampsia. Which nursing actions should be included in the care
plan for this client? SATA.
Keep the room semi-dark.Initiate seizure precautions.Pad the side rails of the
bed.Avoid environmental stimulation.
The labor room nurse assists with the administration of a lumbar epidural
block. How should the nurse check for the major side effect associated with
this type of regional anesthesia?
*A major side effect of a lumbar epidural block is hypotension due to
vasodilation and reduced venous return. Blood pressure should be monitored
frequently, initially every 1-2 minutes for 15 minutes, then every 10-15 minutes.
Reflexes, temperature, and apical pulse are not specific to this anesthesia.
Monitoring the mother's blood pressure
After an amniotomy(WATER BREAKING), the nurse immediately assesses the
fetal heart rate for at least 1 minute to detect changes associated with prolapse
or compression of the umbilical cord. The nurse also notes the quantity, color,
and odor of the amniotic fluid. Which of the following actions should the nurse
prioritize next?
Continue to monitor the fetal heart rate and document findings.
The goal for a woman with partial premature separation of the
placenta/ABRUPTIO PLACENTTAE is, "The woman will not exhibit signs of
fetal distress." Which outcome, documented by the nurse, would indicate that
this goal has been achieved?
Rationale:The fetal heart rate (FHR) reflects fetal well-being, indicating that the
fetus is responding appropriately to labor stress. In cases of partial premature
separation of the placenta, a stable FHR suggests the fetus is not in distress.
, Page 4 of 103
Short-term variability present
The nurse is administering magnesium sulfate to a client for preeclampsia(
HYPERTENSIVE) at 34 weeks gestation. What is the priority nursing action for
this client?
Schedule a non-stress test every 4 hours to assess fetal well-being.
The nurse is caring for a client in active labor. Which nursing intervention
would be the best method to prevent fetal heart rate decelerations?
Encourage an upright or side-lying maternal position.
The nurse is preparing to administer an analgesic to a client in labor. Which
analgesic is contraindicated for a client who has a history of opioid
dependency?
Rationale:
Butorphanol tartrate is a mixed agonist-antagonist opioid analgesic.
It contraindicated for clients with a history of opioid dependency because it
can trigger withdrawal symptoms.This occurs due to its antagonistic
properties on opioid receptors, leading to withdrawal symptoms in opioid-
dependent clients.
Butorphanol tartrate(relieve pain/opioid)
The nurse in a delivery room is assessing a client immediately after delivery of
the placenta. Which maternal observation could indicate uterine
inversion(inside/out) and require immediate intervention?
A soft and boggy uterus(uterine atony)
The nurse is caring for a client in the transition phase of the first stage of
labor. The client is experiencing uterine contractions every 2 minutes and she
cries out in pain with each contraction. What is the nurse's best interpretation
of this client's behavior?
Fear of losing control
A pregnant client is admitted in labor. The nursing assessment reveals that the
client's hemoglobin and hematocrit levels are low, indicating anemia. What
should the nurse observe for throughout the client's labor?
Rationale: Anemia during labor increases the risk of postpartum hemorrhage.
The nurse should monitor for excessive bleeding or difficulty controlling
bleeding after delivery.
Hemorrhage(heavy bleeding)
