ATI NSG 4525 Intrapartum Exam Questions with Correct Answers
Question 1:
A nurse is observing the electronic fetal heart rate monitor for a client who is at 40 weeks of
gestation and is in labor. The nurse should suspect cord compression when she observes which
of the following patterns?
-Early decelerations
-Accelerations
-Late decelerations
-Variable decelerations
Answer:
Variable decelerations -
Question 2:
Variable decelerations occur when the umbilical cord becomes compressed and disrupts the
flow of oxygen to the fetus. A nurse in the labor and delivery unit is caring for a client who is
undergoing external fetal monitoring. the nurse observes the fetal heart rate begins to slow
after the start of a contraction and the lowest rate occurs after the peak of the contraction.
Which of the following actions should the nurse take first?
-Place the client in the lateral position.
-Increase the rate of maintenance IV infusion.
-Elevate the client's legs.
-Administer oxygen using a nonrebreather mask.
Answer:
Place the client in the lateral position. -
Question 3:
This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental
perfusion. Placing the client in the lateral position is the first action the nurse should take. A
nurse is assessing a client who is in active labor and notes that the presenting part is at 0
station. Which of the following is the correct interpretation of this clinical finding?
-The fetal head is in the left occiput posterior position.
-The largest fetal diameter has passed through the pelvic outlet.
-The posterior fontanel is palpable.
-The lowermost portion of the fetus is at the level of the ischial spines.
Answer:
The lowermost portion of the fetus is at the level of the ischial spines. -
The presenting part is at 0 station when its lowermost portion is at the level of an imaginary
line drawn between the client's ischial spines. Levels above the ischial spines are negative
, values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3.
Question 4:
A nurse is caring for a client who is in labor and had an external fetal monitor. The nurse
observed late deceleration on the monitor strip and interprets them as indicating which of the
following?
-Uteroplacental insufficiency
-Maternal bradycardia
-Umbilical cord compression
-Fetal head compression
Answer:
Uteroplacental insufficiency -
Question 5:
The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late
decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic.
They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar
score. A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client
has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood
pressure reading as 82/52mmHg. Which of the following nursing interventions should the nurse
perform?
-Prepare for a cesarean birth.
-Assist the client to an upright position.
-Prepare for an immediate vaginal delivery.
-Assist the client to turn onto her side.
Answer:
Assist the client to turn onto her side. -
Question 6:
Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena
cava. Turning the client to her right side relieves this pressure and restores blood pressure to
the expected reference range. A nurse is caring for a client following an amniotomy who is now
in the active phase of the first stage of labor. Which of the following actions should the nurse
implement with this client?
-Maintain the client in the lithotomy position.
-Perform vaginal examinations frequently.
-Remind the client to bear down with each contraction.
-Encourage the client to empty her bladder every 2 hr.
Answer:
Question 1:
A nurse is observing the electronic fetal heart rate monitor for a client who is at 40 weeks of
gestation and is in labor. The nurse should suspect cord compression when she observes which
of the following patterns?
-Early decelerations
-Accelerations
-Late decelerations
-Variable decelerations
Answer:
Variable decelerations -
Question 2:
Variable decelerations occur when the umbilical cord becomes compressed and disrupts the
flow of oxygen to the fetus. A nurse in the labor and delivery unit is caring for a client who is
undergoing external fetal monitoring. the nurse observes the fetal heart rate begins to slow
after the start of a contraction and the lowest rate occurs after the peak of the contraction.
Which of the following actions should the nurse take first?
-Place the client in the lateral position.
-Increase the rate of maintenance IV infusion.
-Elevate the client's legs.
-Administer oxygen using a nonrebreather mask.
Answer:
Place the client in the lateral position. -
Question 3:
This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental
perfusion. Placing the client in the lateral position is the first action the nurse should take. A
nurse is assessing a client who is in active labor and notes that the presenting part is at 0
station. Which of the following is the correct interpretation of this clinical finding?
-The fetal head is in the left occiput posterior position.
-The largest fetal diameter has passed through the pelvic outlet.
-The posterior fontanel is palpable.
-The lowermost portion of the fetus is at the level of the ischial spines.
Answer:
The lowermost portion of the fetus is at the level of the ischial spines. -
The presenting part is at 0 station when its lowermost portion is at the level of an imaginary
line drawn between the client's ischial spines. Levels above the ischial spines are negative
, values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3.
Question 4:
A nurse is caring for a client who is in labor and had an external fetal monitor. The nurse
observed late deceleration on the monitor strip and interprets them as indicating which of the
following?
-Uteroplacental insufficiency
-Maternal bradycardia
-Umbilical cord compression
-Fetal head compression
Answer:
Uteroplacental insufficiency -
Question 5:
The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late
decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic.
They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar
score. A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client
has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood
pressure reading as 82/52mmHg. Which of the following nursing interventions should the nurse
perform?
-Prepare for a cesarean birth.
-Assist the client to an upright position.
-Prepare for an immediate vaginal delivery.
-Assist the client to turn onto her side.
Answer:
Assist the client to turn onto her side. -
Question 6:
Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena
cava. Turning the client to her right side relieves this pressure and restores blood pressure to
the expected reference range. A nurse is caring for a client following an amniotomy who is now
in the active phase of the first stage of labor. Which of the following actions should the nurse
implement with this client?
-Maintain the client in the lithotomy position.
-Perform vaginal examinations frequently.
-Remind the client to bear down with each contraction.
-Encourage the client to empty her bladder every 2 hr.
Answer:
