PN 131 Quiz 3 NCLEX Practice
Questions and Answers 2024/2025
A pregnant woman's amniotic membranes rupture. Prolapsed umbilical cord is suspected.
What intervention would be the top priority?
a. Placing the woman in the knee-chest position
b. Covering the cord in sterile gauze soaked in saline
c. Preparing the woman for a cesarean birth
d. Starting oxygen by face mask
A
The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or
the knee-chest position, on all fours) in which gravity keeps the pressure of the presenting part
off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman
for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the
event of a prolapsed cord, the intervention of top priority would be positioning the mother to
relieve cord compression.
Nurses should be aware that the induction of labor:
a. Can be achieved by external and internal version techniques.
b. Is also known as a trial of labor (TOL).
c. Is almost always done for medical reasons.
d. Is rated for viability by a Bishop score.
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D
A high score (above 6) is predictive of successful labor induction because the cervix has
ripened or softened in preparation for labor. Version is turning of the fetus to a better
position by a physician for an easier or safer birth. A trial of labor is the observance of a
woman and her fetus for several hours of active labor to assess the safety of vaginal birth.
Two thirds of cases of induced labor are elective and are not done for medical reasons.
With regard to the process of augmentation of labor, the nurse should be aware that it:
a. Is part of the active management of labor that is instituted when the labor process is
unsatisfactory.
b. Relies on more invasive methods when oxytocin and amniotomy have failed.
c. Is a modern management term to cover up the negative connotations of forceps-assisted
birth.
d. Uses vacuum cups.
A
Augmentation is part of the active management of labor that stimulates uterine contractions
after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and
oxytocin infusion, as well as some gentler, noninvasive methods. Forceps-assisted births and
vacuum-assisted births are appropriately used at the end of labor and are not part of
augmentation.
The nurse practicing in a labor setting knows that the woman most at risk for uterine rupture is:
a. A gravida 3 who has had two low-segment transverse cesarean births.
b. A gravida 2 who had a low-segment vertical incision for delivery of a 10-pound infant.
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c. A gravida 5 who had two vaginal births and two cesarean births.
d. A gravida 4 who has had all cesarean births.
D
The risk of uterine rupture increases for the patient who has had multiple prior births with no
vaginal births. As the number of prior uterine incisions increases, so does the risk for uterine
rupture. Low-segment transverse cesarean scars do not predispose the patient to uterine
rupture.
The nurse is monitoring a pregnant client after amniotomy. Which observation would indicate
a likelihood of umbilical cord compression?
A. The fetal heart rate (FHR) confirms tachycardia.
B. The client's vaginal drainage has a foul-smell.
C. The client has maternal chills frequently.
D. The fetal heart rate (FHR) has variable decelerations.
D
(Amniotomy is performed in a pregnant client in order to rupture the membranes artificially.
After the procedure, the nurse should closely monitor the FHR. Reduced FHR and variable
decelerations in FHR indicate that the client's umbilical cord is compressed. The nurse should
immediately inform the primary health care provider of the client's condition. Tachycardia or
increased FHR are common manifestations observed after amniotomy. Tachycardia does not
require immediate clinical action. Maternal chills and foul-smelling vaginal discharge after
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