LABOR & DELIVERY SAUNDERS
NCLEX EXAM 2025 QUESTIONS AND
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 - ANS 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 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.
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,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. - ANS 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.
Place the mother in a supine position.
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,3.
Increase the rate of the oxytocin (Pitocin) intravenous infusion.
4.
Document the findings and continue to monitor the fetal patterns. - ANS 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.
White blood cell count of 12,000 cells/mm3 - ANS 2
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, 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 - ANS 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.
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NCLEX EXAM 2025 QUESTIONS AND
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 - ANS 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 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.
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 1
,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. - ANS 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.
Place the mother in a supine position.
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 2
,3.
Increase the rate of the oxytocin (Pitocin) intravenous infusion.
4.
Document the findings and continue to monitor the fetal patterns. - ANS 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.
White blood cell count of 12,000 cells/mm3 - ANS 2
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 3
, 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 - ANS 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.
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 4
