Labor & Delivery Saunders NCLEX questions 80Qw/exp
Questions & Answers
The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as
being at the most risk for developing disseminated intravascular coagulation?
1.
A primigravida with mild preeclampsia
2.
A primigravida who delivered a 10-lb infant 3 hours ago
3.
A gravida II who has just been diagnosed with dead fetus syndrome
4.
A gravida IV who delivered 8 hours ago and has lost 500 mL of blood - Answer ✔✔ - 3
In a pregnant client, disseminated intravascular coagulation (DIC) is a condition in which the clotting
cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is
considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is
https://www.stuvia.com/user/Wisdoms
,not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for
DIC; however, a loss of 500 mL is not considered hemorrhage.
he nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is
beginning the second stage of labor?
1.
The contractions are regular.
2.
The membranes have ruptured.
3.
The cervix is dilated completely.
4.
The client begins to expel clear vaginal fluid. - Answer ✔✔ - 3.
The second stage of labor begins when the cervix is dilated completely and ends with birth of the
neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur
in stage 1.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse
is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most
appropriate nursing action?
1.
Administer oxygen via face mask.
2.
https://www.stuvia.com/user/Wisdoms
,Place the mother in a supine position.
3.
Increase the rate of the oxytocin (Pitocin) intravenous infusion.
4.
Document the findings and continue to monitor the fetal patterns. - Answer ✔✔ - 1
Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow
and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute
via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the
fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior
vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The
oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting
from stimulation of contractions by this medication. Although the nurse would document the
occurrence, option 4 would delay necessary treatment.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which
assessment finding would indicate the need to contact the health care provider?
1.
Hemoglobin of 11 g/dL
2.
Fetal heart rate of 180 beats/minute
3.
Maternal pulse rate of 85 beats/minute
4.
https://www.stuvia.com/user/Wisdoms
, White blood cell count of 12,000 cells/mm3 - Answer ✔✔ - 2
A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could
indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal
maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in
plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15
beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and
kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second
trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 cells/mm3 (up to
18,000 cells/mm3). During the immediate postpartum period, the white blood cell count may be 25,000
to 30,000 cells/mm3 because of increased leukocytosis that occurs during delivery.
The nurse is reviewing the record of a client in the labor room and notes that the health care provider
has documented that the fetal presenting part is at the -1 station. This documented finding indicates
that the fetal presenting part is located at which area?
1.
1 inch below the coccyx
2.
1 inch below the iliac crest
3.
1 cm above the ischial spine
4.
1 fingerbreadth below the symphysis pubis - Answer ✔✔ - 3
Station is the measurement of the progress of descent in centimeters above or below the midplane from
the presenting part to the ischial spine. It is measured in centimeters, and noted as a negative number
above the line and as a positive number below the line. At the negative 1 (-1) station, the fetal
presenting part is 1 cm above the ischial spine.
https://www.stuvia.com/user/Wisdoms
Questions & Answers
The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as
being at the most risk for developing disseminated intravascular coagulation?
1.
A primigravida with mild preeclampsia
2.
A primigravida who delivered a 10-lb infant 3 hours ago
3.
A gravida II who has just been diagnosed with dead fetus syndrome
4.
A gravida IV who delivered 8 hours ago and has lost 500 mL of blood - Answer ✔✔ - 3
In a pregnant client, disseminated intravascular coagulation (DIC) is a condition in which the clotting
cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is
considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is
https://www.stuvia.com/user/Wisdoms
,not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for
DIC; however, a loss of 500 mL is not considered hemorrhage.
he nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is
beginning the second stage of labor?
1.
The contractions are regular.
2.
The membranes have ruptured.
3.
The cervix is dilated completely.
4.
The client begins to expel clear vaginal fluid. - Answer ✔✔ - 3.
The second stage of labor begins when the cervix is dilated completely and ends with birth of the
neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur
in stage 1.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse
is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most
appropriate nursing action?
1.
Administer oxygen via face mask.
2.
https://www.stuvia.com/user/Wisdoms
,Place the mother in a supine position.
3.
Increase the rate of the oxytocin (Pitocin) intravenous infusion.
4.
Document the findings and continue to monitor the fetal patterns. - Answer ✔✔ - 1
Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow
and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute
via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the
fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior
vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The
oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting
from stimulation of contractions by this medication. Although the nurse would document the
occurrence, option 4 would delay necessary treatment.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which
assessment finding would indicate the need to contact the health care provider?
1.
Hemoglobin of 11 g/dL
2.
Fetal heart rate of 180 beats/minute
3.
Maternal pulse rate of 85 beats/minute
4.
https://www.stuvia.com/user/Wisdoms
, White blood cell count of 12,000 cells/mm3 - Answer ✔✔ - 2
A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could
indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal
maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in
plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15
beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and
kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second
trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 cells/mm3 (up to
18,000 cells/mm3). During the immediate postpartum period, the white blood cell count may be 25,000
to 30,000 cells/mm3 because of increased leukocytosis that occurs during delivery.
The nurse is reviewing the record of a client in the labor room and notes that the health care provider
has documented that the fetal presenting part is at the -1 station. This documented finding indicates
that the fetal presenting part is located at which area?
1.
1 inch below the coccyx
2.
1 inch below the iliac crest
3.
1 cm above the ischial spine
4.
1 fingerbreadth below the symphysis pubis - Answer ✔✔ - 3
Station is the measurement of the progress of descent in centimeters above or below the midplane from
the presenting part to the ischial spine. It is measured in centimeters, and noted as a negative number
above the line and as a positive number below the line. At the negative 1 (-1) station, the fetal
presenting part is 1 cm above the ischial spine.
https://www.stuvia.com/user/Wisdoms
