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NUR 254 EXAM 2 – INTRAPARTUM & POSTPARTUM
NURSING COMPLETE (140) CURRENT TESTING
QUESTIONS AND CORRECT ANSWERS WITH DETAILED
RATIONALES.
NURSING
Prepare effectively for the NUR 254 Exam 2 with this focused study resource. It
supports review of intrapartum and postpartum nursing concepts, labor management,
maternal assessment, postpartum recovery, complications, and nursing
interventions. Use the material to reinforce your understanding, review key topics, and
identify areas that may require additional study. This resource is suited for nursing
students, maternal-child health learners, and candidates preparing for NUR 254 Exam
2.
MULTIPLE CHOICE.
SECTION I: INTRAPARTUM NURSING – STAGES OF LABOR & FETAL
MONITORING (Questions 1-25)
1. A primigravida at 38 weeks of gestation is admitted with contractions
every 5 minutes. What is the priority nursing assessment?
A) Maternal blood pressure
B) Cervical dilation
C) Fetal heart rate and pattern
D) Pain level
Answer: C
Rationale: Fetal heart rate monitoring is the absolute priority to assess
fetal well-being and oxygenation during labor.
2. Which fetal position is most favorable for a vaginal delivery?
A) Occiput posterior
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B) Occiput transverse
C) Occiput anterior
D) Breech
Answer: C
Rationale: Occiput anterior (OA) is the optimal position because the fetal
head is fully flexed, allowing the smallest suboccipitobregmatic diameter
to pass through the maternal pelvis.
3. A nurse is evaluating the progress of labor. Which finding indicates the
patient is in the active phase of the first stage of labor?
A) Cervical dilation 1-4 cm with contractions every 10-15 minutes
B) Cervical dilation 4-7 cm with contractions every 2-5 minutes
C) Cervical dilation 8-10 cm with contractions every 1-2 minutes
D) Complete cervical dilation with urge to push
Answer: B
Rationale: The active phase of the first stage of labor is characterized by
cervical dilation of 4-7 cm with contractions occurring every 2-5 minutes.
The latent phase is 0-3 cm, and the transition phase is 8-10 cm.
4. The nurse is assessing a laboring patient and notes the fetal station is -
3. This indicates that the fetal presenting part is:
A) At the level of the ischial spines
B) 3 cm above the ischial spines
C) 3 cm below the ischial spines
D) Engaged in the pelvis
Answer: B
Rationale: Fetal station is measured in centimeters above or below the
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maternal ischial spines. A station of -3 indicates the presenting part is 3
cm above the ischial spines. Station 0 is at the spines, and +3 is at the
pelvic outlet.
5. A nurse is assessing the fetal heart rate (FHR) and notes a pattern of
late decelerations. What is the priority nursing action?
A) Increase the IV fluid rate
B) Position the mother on her left side
C) Administer oxygen via face mask
D) Notify the healthcare provider immediately
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency and
fetal hypoxia. The nurse should notify the healthcare provider
immediately while implementing interventions such as positioning the
mother on her left side, increasing IV fluids, and administering oxygen.
6. Which statement is the best rationale for assessing maternal vital signs
between contractions?
A) During a contraction, assessing fetal heart rates is the priority
B) Maternal circulating blood volume increases temporarily during
contractions
C) Maternal blood flow to the heart is reduced during contractions
D) Vital signs taken during contractions are not accurate
Answer: B
Rationale: Maternal circulating blood volume increases temporarily
during contractions, which can affect blood pressure and heart rate
readings. Vital signs should be assessed between contractions for
accurate baseline measurements.
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7. A patient in active labor is experiencing strong, frequent contractions
and reports intense back pain. The nurse assesses the fetal position as
occiput posterior. Which intervention should the nurse implement?
A) Encourage the patient to lie supine
B) Apply counterpressure to the sacrum
C) Administer an opioid analgesic
D) Prepare for immediate cesarean delivery
Answer: B
Rationale: Occiput posterior position often causes intense back labor.
Applying counterpressure to the sacrum can help relieve back pain.
Positioning the patient on her side or hands and knees may also facilitate
fetal rotation.
8. The nurse administers oxytocin (Pitocin) to a patient in labor. What is
the primary indication for this medication during labor?
A) To stop preterm labor
B) To augment or induce uterine contractions
C) To reduce postpartum hemorrhage
D) To promote cervical ripening
Answer: B
Rationale: During the intrapartum period, oxytocin's primary indication is
to stimulate uterine contractions for induction or augmentation of labor.
While it is also used for postpartum hemorrhage, that is a secondary
indication after delivery.
NUR 254 EXAM 2 – INTRAPARTUM & POSTPARTUM
NURSING COMPLETE (140) CURRENT TESTING
QUESTIONS AND CORRECT ANSWERS WITH DETAILED
RATIONALES.
NURSING
Prepare effectively for the NUR 254 Exam 2 with this focused study resource. It
supports review of intrapartum and postpartum nursing concepts, labor management,
maternal assessment, postpartum recovery, complications, and nursing
interventions. Use the material to reinforce your understanding, review key topics, and
identify areas that may require additional study. This resource is suited for nursing
students, maternal-child health learners, and candidates preparing for NUR 254 Exam
2.
MULTIPLE CHOICE.
SECTION I: INTRAPARTUM NURSING – STAGES OF LABOR & FETAL
MONITORING (Questions 1-25)
1. A primigravida at 38 weeks of gestation is admitted with contractions
every 5 minutes. What is the priority nursing assessment?
A) Maternal blood pressure
B) Cervical dilation
C) Fetal heart rate and pattern
D) Pain level
Answer: C
Rationale: Fetal heart rate monitoring is the absolute priority to assess
fetal well-being and oxygenation during labor.
2. Which fetal position is most favorable for a vaginal delivery?
A) Occiput posterior
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B) Occiput transverse
C) Occiput anterior
D) Breech
Answer: C
Rationale: Occiput anterior (OA) is the optimal position because the fetal
head is fully flexed, allowing the smallest suboccipitobregmatic diameter
to pass through the maternal pelvis.
3. A nurse is evaluating the progress of labor. Which finding indicates the
patient is in the active phase of the first stage of labor?
A) Cervical dilation 1-4 cm with contractions every 10-15 minutes
B) Cervical dilation 4-7 cm with contractions every 2-5 minutes
C) Cervical dilation 8-10 cm with contractions every 1-2 minutes
D) Complete cervical dilation with urge to push
Answer: B
Rationale: The active phase of the first stage of labor is characterized by
cervical dilation of 4-7 cm with contractions occurring every 2-5 minutes.
The latent phase is 0-3 cm, and the transition phase is 8-10 cm.
4. The nurse is assessing a laboring patient and notes the fetal station is -
3. This indicates that the fetal presenting part is:
A) At the level of the ischial spines
B) 3 cm above the ischial spines
C) 3 cm below the ischial spines
D) Engaged in the pelvis
Answer: B
Rationale: Fetal station is measured in centimeters above or below the
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maternal ischial spines. A station of -3 indicates the presenting part is 3
cm above the ischial spines. Station 0 is at the spines, and +3 is at the
pelvic outlet.
5. A nurse is assessing the fetal heart rate (FHR) and notes a pattern of
late decelerations. What is the priority nursing action?
A) Increase the IV fluid rate
B) Position the mother on her left side
C) Administer oxygen via face mask
D) Notify the healthcare provider immediately
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency and
fetal hypoxia. The nurse should notify the healthcare provider
immediately while implementing interventions such as positioning the
mother on her left side, increasing IV fluids, and administering oxygen.
6. Which statement is the best rationale for assessing maternal vital signs
between contractions?
A) During a contraction, assessing fetal heart rates is the priority
B) Maternal circulating blood volume increases temporarily during
contractions
C) Maternal blood flow to the heart is reduced during contractions
D) Vital signs taken during contractions are not accurate
Answer: B
Rationale: Maternal circulating blood volume increases temporarily
during contractions, which can affect blood pressure and heart rate
readings. Vital signs should be assessed between contractions for
accurate baseline measurements.
, Page 4 of 46
7. A patient in active labor is experiencing strong, frequent contractions
and reports intense back pain. The nurse assesses the fetal position as
occiput posterior. Which intervention should the nurse implement?
A) Encourage the patient to lie supine
B) Apply counterpressure to the sacrum
C) Administer an opioid analgesic
D) Prepare for immediate cesarean delivery
Answer: B
Rationale: Occiput posterior position often causes intense back labor.
Applying counterpressure to the sacrum can help relieve back pain.
Positioning the patient on her side or hands and knees may also facilitate
fetal rotation.
8. The nurse administers oxytocin (Pitocin) to a patient in labor. What is
the primary indication for this medication during labor?
A) To stop preterm labor
B) To augment or induce uterine contractions
C) To reduce postpartum hemorrhage
D) To promote cervical ripening
Answer: B
Rationale: During the intrapartum period, oxytocin's primary indication is
to stimulate uterine contractions for induction or augmentation of labor.
While it is also used for postpartum hemorrhage, that is a secondary
indication after delivery.
