MOTHER BABY NCLEX FINAL PREPARATION
EXAM QUESTIONS WITH COMPLETE SOLUTIONS
The patient is 8cm dilated and saying they have to push, the nurse should encourage
the patient to do what? - CORRECT ANSWER-encourage them to pant w/ pursed
lips
rationale: this will keep them breathing and prevent them from pushing
The nursing student is monitoring fetal heart strips, the instructor knows that the
student understands the difference between time of contraction and duration of
contraction when they state... - CORRECT ANSWER-Time of contraction is from
the beginning of one contraction to the beginning of the next contraction and the
duration of contraction is time in seconds from the beginning of the contraction until
it's completion
You're caring for a patient who is 2cm dilated, her contractions are 20 seconds long
and 15 minutes apart. Based on this data you know that she is in which stage and
phase of labor - CORRECT ANSWER-1st stage latent phase
Rationale: the first stage of labor has three phases in the first phase (latent) the
cervix is dilated 0-3cm, contractions 30-60 seconds long and 5-30 minutes apart
You are the nursing instructor on the mother baby unit. The student nurse is caring
for a patient in the latent phase of labor. What interventions do you expect the
student to perform for this patient. Select all that apply
start IV
Encourage ambulation
Fetal monitoring
Encourage bed rest
provide pain management
breathing techniques - CORRECT ANSWER-start IV, encourage ambulation, fetal
monitoring, breathing techniques
Your patient is 7cm dilated and her contractions are 60 seconds long and 3 minutes
apart. She is acting fatigued in states that she is in a lot of pain and wants to push
this baby out already because she can't take it much longer. What is the best way that
you can respond as the nurse?
"Take a nap, it will help you relax while you wait to be able to push"
"Ill call the Dr. and see if we can get you an epidural but don't push yet"
"We do not want you to push until you are fully dilated at 10cm I just checked and
Mother Baby NCLEX Final Preparation exam questions with complete solutions
,you are at 7, let's try to reposition you and use the breathing techniques you learned
at your birthing classes to make you more comfortable, you can do this"
"Here's a pillow and a cold cloth, your husband can give you a back rub to see if that
helps while I go chart and check on some other patients, let me know if you need
anything else" - CORRECT ANSWER-"We do not want you to push until you are
fully dilated at 10cm I just checked and you are at 7, let's try to reposition you and
use the breathing techniques you learned at your birthing classes to make you more
comfortable, you can do this"
Rationale: Pt is in the active phase of labor, she is more dependent and less able to
meet self needs. As the nurse you should manage her pain, encourage her to
maintain her breathing pattern, provide a quiet environment and support, provide
back rubs, pillows, cool cloth to the forehead, ointment for dry mouth, and assist
with position changes
You just got report during shift change that your patient is in the transition phase of
labor. What do you anticipate before going into the room to assess her?
A. Pt is with the doctor pushing the baby out
B. Pt just got an epidural
C. Pt is 9cm dilated with contractions 50 seconds long and 3 minutes apart
D. Pt is 7cm dilated with contractions 60 seconds long and 3 minutes apart -
CORRECT ANSWER-C. During the transition phase pt is dilated 8-10cm with
contractions 45-90 seconds long and 2-3 minutes apart. strong. Pt may be restless
and irritable. She won't push until 10 cm dilated and she would have already gotten
her epidural if she was going to have one. The other choice describes the active
phase
When you go into a pt's room she is 10cm dilated and feels the urge to push. You
assist the patient to push until the head is visible and notify the doctor that she is
ready for delivery. You know the student observing the delivery understands the
stages of labor when she states,
A. The patient is in the transition phase of labor, first stage
B. The patient is in the Active stage of labor
C. The patient is in the second stage of labor
D. The patient is in the third stage of labor - CORRECT ANSWER-C. The second
stage of labor is from full dilation of the cervix to delivery of the baby
When questioning the student about the purpose of an episiotomy the instructor
knows they understand when they say which of the following select all that apply
A. It will prevent lacerations
B. It will prevent tears
C. It will give the baby more room to breathe
Mother Baby NCLEX Final Preparation exam questions with complete solutions
, D. It will help with the delivery of the baby
E. It will decrease the amount of lochia during the postpartum period - CORRECT
ANSWER-A. B. C. The purpose of an episiotomy is to aid in the delivery of the
baby. It prevents lacerations and tearing and is usually performed at the end of the
second stage of labor if necessary
You are the nursing instructor on the labor and delivery unit. When discussing the
stages of labor you know the student understands the difference between the third
and fourth stages of labor when they state,
A. The third stage of labor is from the birth of baby to delivery of placenta and
fourth stage is the first 6 hours after delivery
B. The third stage of labor is the birth of the baby and the fourth stage is the delivery
of the placenta
C. The third stage of labor is from the birth of the baby to the delivery of the
placenta and the fourth stage is the first 1-4 hours after delivery
D. The third stage of labor is the birth of the baby and the fourth stage is from the
delivery of the placenta to the first 1-4 hours after delivery - CORRECT ANSWER-
B. The third stage of labor is from the birth of the baby to expulsion of the placenta
and the fourth stage of labor is the first 1-4 hrs after delivery
Which of the following are indications for forceps delivery select all that apply
A. Mom can no longer push
B. Baby's condition deteriorating
C. C-section cannot be done
D. Pt throwing up
E. Pt had a large bowel movement during delivery - CORRECT ANSWER-A. B. C.
Forceps delivery is utilized when mom can no longer push, baby is deteriorating,
and/or C-section cannot be done
What are you going to take into consideration as the nurse during a forceps delivery
SATA
A. Educate mom not to push unless instructed
B. Assess hematomas
C. Assess lacerations
D. Assess for bladder and urethral injuries - CORRECT ANSWER-All of these
What Braxton Hicks Contractions - CORRECT ANSWER-Painless irregular
contractions that do not change in frequency, duration, or intensity, and do not
produce cervical changes. They can occur throughout pregnancy and can be more
evident, frequent, and painful as true labor approaches
Mother Baby NCLEX Final Preparation exam questions with complete solutions
EXAM QUESTIONS WITH COMPLETE SOLUTIONS
The patient is 8cm dilated and saying they have to push, the nurse should encourage
the patient to do what? - CORRECT ANSWER-encourage them to pant w/ pursed
lips
rationale: this will keep them breathing and prevent them from pushing
The nursing student is monitoring fetal heart strips, the instructor knows that the
student understands the difference between time of contraction and duration of
contraction when they state... - CORRECT ANSWER-Time of contraction is from
the beginning of one contraction to the beginning of the next contraction and the
duration of contraction is time in seconds from the beginning of the contraction until
it's completion
You're caring for a patient who is 2cm dilated, her contractions are 20 seconds long
and 15 minutes apart. Based on this data you know that she is in which stage and
phase of labor - CORRECT ANSWER-1st stage latent phase
Rationale: the first stage of labor has three phases in the first phase (latent) the
cervix is dilated 0-3cm, contractions 30-60 seconds long and 5-30 minutes apart
You are the nursing instructor on the mother baby unit. The student nurse is caring
for a patient in the latent phase of labor. What interventions do you expect the
student to perform for this patient. Select all that apply
start IV
Encourage ambulation
Fetal monitoring
Encourage bed rest
provide pain management
breathing techniques - CORRECT ANSWER-start IV, encourage ambulation, fetal
monitoring, breathing techniques
Your patient is 7cm dilated and her contractions are 60 seconds long and 3 minutes
apart. She is acting fatigued in states that she is in a lot of pain and wants to push
this baby out already because she can't take it much longer. What is the best way that
you can respond as the nurse?
"Take a nap, it will help you relax while you wait to be able to push"
"Ill call the Dr. and see if we can get you an epidural but don't push yet"
"We do not want you to push until you are fully dilated at 10cm I just checked and
Mother Baby NCLEX Final Preparation exam questions with complete solutions
,you are at 7, let's try to reposition you and use the breathing techniques you learned
at your birthing classes to make you more comfortable, you can do this"
"Here's a pillow and a cold cloth, your husband can give you a back rub to see if that
helps while I go chart and check on some other patients, let me know if you need
anything else" - CORRECT ANSWER-"We do not want you to push until you are
fully dilated at 10cm I just checked and you are at 7, let's try to reposition you and
use the breathing techniques you learned at your birthing classes to make you more
comfortable, you can do this"
Rationale: Pt is in the active phase of labor, she is more dependent and less able to
meet self needs. As the nurse you should manage her pain, encourage her to
maintain her breathing pattern, provide a quiet environment and support, provide
back rubs, pillows, cool cloth to the forehead, ointment for dry mouth, and assist
with position changes
You just got report during shift change that your patient is in the transition phase of
labor. What do you anticipate before going into the room to assess her?
A. Pt is with the doctor pushing the baby out
B. Pt just got an epidural
C. Pt is 9cm dilated with contractions 50 seconds long and 3 minutes apart
D. Pt is 7cm dilated with contractions 60 seconds long and 3 minutes apart -
CORRECT ANSWER-C. During the transition phase pt is dilated 8-10cm with
contractions 45-90 seconds long and 2-3 minutes apart. strong. Pt may be restless
and irritable. She won't push until 10 cm dilated and she would have already gotten
her epidural if she was going to have one. The other choice describes the active
phase
When you go into a pt's room she is 10cm dilated and feels the urge to push. You
assist the patient to push until the head is visible and notify the doctor that she is
ready for delivery. You know the student observing the delivery understands the
stages of labor when she states,
A. The patient is in the transition phase of labor, first stage
B. The patient is in the Active stage of labor
C. The patient is in the second stage of labor
D. The patient is in the third stage of labor - CORRECT ANSWER-C. The second
stage of labor is from full dilation of the cervix to delivery of the baby
When questioning the student about the purpose of an episiotomy the instructor
knows they understand when they say which of the following select all that apply
A. It will prevent lacerations
B. It will prevent tears
C. It will give the baby more room to breathe
Mother Baby NCLEX Final Preparation exam questions with complete solutions
, D. It will help with the delivery of the baby
E. It will decrease the amount of lochia during the postpartum period - CORRECT
ANSWER-A. B. C. The purpose of an episiotomy is to aid in the delivery of the
baby. It prevents lacerations and tearing and is usually performed at the end of the
second stage of labor if necessary
You are the nursing instructor on the labor and delivery unit. When discussing the
stages of labor you know the student understands the difference between the third
and fourth stages of labor when they state,
A. The third stage of labor is from the birth of baby to delivery of placenta and
fourth stage is the first 6 hours after delivery
B. The third stage of labor is the birth of the baby and the fourth stage is the delivery
of the placenta
C. The third stage of labor is from the birth of the baby to the delivery of the
placenta and the fourth stage is the first 1-4 hours after delivery
D. The third stage of labor is the birth of the baby and the fourth stage is from the
delivery of the placenta to the first 1-4 hours after delivery - CORRECT ANSWER-
B. The third stage of labor is from the birth of the baby to expulsion of the placenta
and the fourth stage of labor is the first 1-4 hrs after delivery
Which of the following are indications for forceps delivery select all that apply
A. Mom can no longer push
B. Baby's condition deteriorating
C. C-section cannot be done
D. Pt throwing up
E. Pt had a large bowel movement during delivery - CORRECT ANSWER-A. B. C.
Forceps delivery is utilized when mom can no longer push, baby is deteriorating,
and/or C-section cannot be done
What are you going to take into consideration as the nurse during a forceps delivery
SATA
A. Educate mom not to push unless instructed
B. Assess hematomas
C. Assess lacerations
D. Assess for bladder and urethral injuries - CORRECT ANSWER-All of these
What Braxton Hicks Contractions - CORRECT ANSWER-Painless irregular
contractions that do not change in frequency, duration, or intensity, and do not
produce cervical changes. They can occur throughout pregnancy and can be more
evident, frequent, and painful as true labor approaches
Mother Baby NCLEX Final Preparation exam questions with complete solutions
