Labor and Delivery (ATI) Revision Exam
Questions Answered Correctly.
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the
following findings is the nurses's priority?
A. pt reports weakness in lower extremities
B. BP 80/56 mmHg
C. T 38.2 (100.8 F)
D. the client reports perfuse itching - Answer B. BP 80/56 mmHg
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients BP is 80/40
mmHg and the fetal HR is 140/min. Which of the following is the priority nursing action?
A. elevate the pt legs
B. monitor VS Q 5 min
C. notify HCP
D. place pt in a lateral position - Answer D. place pt in a lateral position
-maslows hierarchy → lateral position w pillow under one of pt hips to relieve pressure on IVC and
improve BP
A nurse in the ED is admitting a client who is at 40 wks gestation, has ruptured membranes, and the
nurse observes the newborn's head is crowing. The pt tells the nurse she wants to push. Which of the
following statements should the nurse make?
A. "you should go ahead and push to assist the deliver"
B. "you should try to pant as the delivery proceeds"
C. "you should try to perform slow=paced breathing"
D. "you should take a deep, cleansing breath and breathe naturally" - Answer B. "you should try to pant
as the delivery proceeds"
, -avoids rapid expulsion of the head
slow-paced breathing = first stage of labor as strength/duration of contractions increase
cleansing breath/breathing naturally = not alleviate/reduce the urge to push at this time
A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the
provider which is documented as: -1. Which of the following interpretations of this finding should the
nurse make?
A. presenting part is 1 cm above the ischial spines
B. presenting part is 1 cm below the ischial spines
C. cervix is 1 cm dilated
D. cervix is effaced 1 cm - Answer A. presenting part is 1 cm above the ischial spines
A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of
the gate control theory of pain?
A. admin prescribed analgesic meds
B. encourage pt to rest between contractions
C. massage the pt back
D. turn pt to left side - Answer C. massage the pt back
-blocking/preventing transmission of pain signals by using distraction techniques
A nurse is admitting a client who is 33 weeks of gestation and has a dx of placenta previa. Which of the
following is the priority nursing action?
A. monitor vaginal bleeding
B. admin glucocorticoids
C. insert an IV cath
Questions Answered Correctly.
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the
following findings is the nurses's priority?
A. pt reports weakness in lower extremities
B. BP 80/56 mmHg
C. T 38.2 (100.8 F)
D. the client reports perfuse itching - Answer B. BP 80/56 mmHg
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients BP is 80/40
mmHg and the fetal HR is 140/min. Which of the following is the priority nursing action?
A. elevate the pt legs
B. monitor VS Q 5 min
C. notify HCP
D. place pt in a lateral position - Answer D. place pt in a lateral position
-maslows hierarchy → lateral position w pillow under one of pt hips to relieve pressure on IVC and
improve BP
A nurse in the ED is admitting a client who is at 40 wks gestation, has ruptured membranes, and the
nurse observes the newborn's head is crowing. The pt tells the nurse she wants to push. Which of the
following statements should the nurse make?
A. "you should go ahead and push to assist the deliver"
B. "you should try to pant as the delivery proceeds"
C. "you should try to perform slow=paced breathing"
D. "you should take a deep, cleansing breath and breathe naturally" - Answer B. "you should try to pant
as the delivery proceeds"
, -avoids rapid expulsion of the head
slow-paced breathing = first stage of labor as strength/duration of contractions increase
cleansing breath/breathing naturally = not alleviate/reduce the urge to push at this time
A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the
provider which is documented as: -1. Which of the following interpretations of this finding should the
nurse make?
A. presenting part is 1 cm above the ischial spines
B. presenting part is 1 cm below the ischial spines
C. cervix is 1 cm dilated
D. cervix is effaced 1 cm - Answer A. presenting part is 1 cm above the ischial spines
A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of
the gate control theory of pain?
A. admin prescribed analgesic meds
B. encourage pt to rest between contractions
C. massage the pt back
D. turn pt to left side - Answer C. massage the pt back
-blocking/preventing transmission of pain signals by using distraction techniques
A nurse is admitting a client who is 33 weeks of gestation and has a dx of placenta previa. Which of the
following is the priority nursing action?
A. monitor vaginal bleeding
B. admin glucocorticoids
C. insert an IV cath
