NSG 210 EXAM 1 QUESTIONS WITH
CORRECT ANSWERS
The nurse is performing a vaginal examination on a client in labor. The nurse finds the
fetal presenting part 1 cm above the ischial spines. How should the nurse document the
fetal position?
1. -1
2. +1
3. Engaged
4. Floating - Answer-Answer 1
If presenting part is above the ischial spines 1 cm, the station is -1. If the presenting part
is 1 cm below the ischial spines, the station is +1. Engaged and floating are not
descriptive of station.
A multigravida client is admitted at 4-cm dilated and is requesting pain medication. The
nurse gives the client an opioid medication. Within 5 minutes, the client tells the nurse
she feels like she needs to have a bowel movement. What should the nurse do first?
1. Have naloxone available in the birthing room
2. Complete a vaginal exam
3. Prepare for birth
4. Document the client's relief due to pain medication - Answer-Answer 2
The feeling of needing to have a bowel movement is commonly caused by pressure on
receptors low in the perineum when the fetal head is creating pressure on them. This
feeling usually indicates advances in fetal station and that the client may be close to
birth. The nurse should respond initially by completing a vaginal exam to validate
current effacement, dilation and station.
A prim gravida client in the second stage of labor feels the urge to push. The client has
had no analgesia or anesthesia. Anatomically, which would be the best position for the
client to assume?
1. Dorsal recumbent
2. Lithotomy
3. Hands and knees
4. Squatting - Answer-Answer 4
Anatomically, the best position for the client to assume is the squatting position because
this enhances pelvic diameters and allows gravity to assist in the expulsion stage of
labor. This position also provides for natural pressure anesthesia as the fetal presenting
part presses on the stretched perineum.
,A 24-year-old prim gravid client who gives birth to a viable term neonate is in the third
stage of labor. Which sign would indicate to the nurse that the placenta is about to be
delivered?
1. The cord lengthens outside the vagina
2. There is a decrease in vaginal bleeding
3. The uterus cannot be palpated
4. The uterus changes to discoid shape - Answer-Answer 1
The most reliable sign the placenta has detached from the uterine wall is lengthening of
the cord outside the vagina. Other signs include a sudden gush of (not decrease)
vaginal blood.
After a lengthy labor process a primigravid client gives birth to a healthy newborn boy
with a moderate amount of skull molding. What information would the nurse include
when explaining to the patient about the condition?
1. It is typically seen with breech births
2. It usually last a few days before resolving
3. It is typically when the brow is the presenting part
4. Surgical intervention may be necessary to relieve the pressure - Answer-Answer 2
Molding occurs with vaginal births and is commonly seen in newborns. This is especially
true with primigravid clients experiencing a lengthy labor process. Parents need to be
reassured that is not permanent and that it typically last a day or tow before resolving.
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete
effacement. The client has severe back pain during this phase of labor. The nurse
explains that the client's severe back pain is most likely caused by the fetal occiput
being in which position.
1. Breech
2. Transverse
3. Posterior
4. Anterior - Answer-Answer 3
When the client has severe back pain during labor, the fetus is most likely in an
occipitoposterior position. This means that the fetal head presses against the client's
sacrum, causing marked discomfort during contractions.
Assessment of a primigravid client in active labor who has had no analgesia or
anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0
station. The nurse should expect the client to exhibit which behavior during this phase of
active labor?
1. Excitement
2. Loss of control
3. Numbness of the legs
4. Feelings of relief - Answer-Answer 2
Assessment findings indicate that the client is in the transition phase of labor. During
this phase, it is not unusual for the clients to exhibit a loss of control or irritability. Leg
tremors, nausea and vomiting and an urge to bear down also are common.
, During the second stage of labor, assessment would include which of the following?
a. Complaints of rectal or perineal pressure
b. Estimated date of birth
c. Fundal height
d. Fetal position - Answer-a. Complaints of rectal or perineal pressure
During the second stage of labor, the nurse would assess for signs typical for this stage,
such as complaints of rectal or perineal pressure. Assessment of estimated date of
birth, fundal height, and fetal position are assessments for the first stage of labor.
Stage 1 of labor includes which phases in the correct order?A. Transition, Latent, Active
B. Active, Latent, Active
C. Active, Transition, Latent
D. Latent, Active, Transition - Answer-D
In stage 1 of labor, during the active phase, the cervix dilates:
a. 0-6 cm
b. 7-9 cm
c. 6-8 cm
d. 8-10 cm - Answer-c
latent: 0-6 cm
active: 6-8 cm
transitional: 8-10 cm
Your laboring patient has transitioned to stage 2 of labor. What changes in the perineum
indicate the birth of the baby is imminent?
a. Increase in meconium-stained fluid and retracting perineum
b. Retracting perineum and anus with an increase of bloody show
c. Rapid and intense contractions
d. Bulging perineum and rectum with an increase in bloody show - Answer-d
an infant shows a tendency to bleed two days after birth. the nurse understands this is
most likely caused by which reason?
a. hemophilia
b. absence of intestinal bacteria and lack of vitamin k
c. an immature liver that is unable to synthesize clotting factors
d. delayed production of red blood cells - Answer-b
a primigravida diagnosed with type 1 diabetes mellitus reviews the insulin regimen with
the nurse. the nurse explains which changes in insulin requirements will occur in
pregnancy?
a. insulin requirements will increase during pregnancy and decrease after delivery
b. insulin. requirements will decrease during pregnancy and increase after delivery
CORRECT ANSWERS
The nurse is performing a vaginal examination on a client in labor. The nurse finds the
fetal presenting part 1 cm above the ischial spines. How should the nurse document the
fetal position?
1. -1
2. +1
3. Engaged
4. Floating - Answer-Answer 1
If presenting part is above the ischial spines 1 cm, the station is -1. If the presenting part
is 1 cm below the ischial spines, the station is +1. Engaged and floating are not
descriptive of station.
A multigravida client is admitted at 4-cm dilated and is requesting pain medication. The
nurse gives the client an opioid medication. Within 5 minutes, the client tells the nurse
she feels like she needs to have a bowel movement. What should the nurse do first?
1. Have naloxone available in the birthing room
2. Complete a vaginal exam
3. Prepare for birth
4. Document the client's relief due to pain medication - Answer-Answer 2
The feeling of needing to have a bowel movement is commonly caused by pressure on
receptors low in the perineum when the fetal head is creating pressure on them. This
feeling usually indicates advances in fetal station and that the client may be close to
birth. The nurse should respond initially by completing a vaginal exam to validate
current effacement, dilation and station.
A prim gravida client in the second stage of labor feels the urge to push. The client has
had no analgesia or anesthesia. Anatomically, which would be the best position for the
client to assume?
1. Dorsal recumbent
2. Lithotomy
3. Hands and knees
4. Squatting - Answer-Answer 4
Anatomically, the best position for the client to assume is the squatting position because
this enhances pelvic diameters and allows gravity to assist in the expulsion stage of
labor. This position also provides for natural pressure anesthesia as the fetal presenting
part presses on the stretched perineum.
,A 24-year-old prim gravid client who gives birth to a viable term neonate is in the third
stage of labor. Which sign would indicate to the nurse that the placenta is about to be
delivered?
1. The cord lengthens outside the vagina
2. There is a decrease in vaginal bleeding
3. The uterus cannot be palpated
4. The uterus changes to discoid shape - Answer-Answer 1
The most reliable sign the placenta has detached from the uterine wall is lengthening of
the cord outside the vagina. Other signs include a sudden gush of (not decrease)
vaginal blood.
After a lengthy labor process a primigravid client gives birth to a healthy newborn boy
with a moderate amount of skull molding. What information would the nurse include
when explaining to the patient about the condition?
1. It is typically seen with breech births
2. It usually last a few days before resolving
3. It is typically when the brow is the presenting part
4. Surgical intervention may be necessary to relieve the pressure - Answer-Answer 2
Molding occurs with vaginal births and is commonly seen in newborns. This is especially
true with primigravid clients experiencing a lengthy labor process. Parents need to be
reassured that is not permanent and that it typically last a day or tow before resolving.
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete
effacement. The client has severe back pain during this phase of labor. The nurse
explains that the client's severe back pain is most likely caused by the fetal occiput
being in which position.
1. Breech
2. Transverse
3. Posterior
4. Anterior - Answer-Answer 3
When the client has severe back pain during labor, the fetus is most likely in an
occipitoposterior position. This means that the fetal head presses against the client's
sacrum, causing marked discomfort during contractions.
Assessment of a primigravid client in active labor who has had no analgesia or
anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0
station. The nurse should expect the client to exhibit which behavior during this phase of
active labor?
1. Excitement
2. Loss of control
3. Numbness of the legs
4. Feelings of relief - Answer-Answer 2
Assessment findings indicate that the client is in the transition phase of labor. During
this phase, it is not unusual for the clients to exhibit a loss of control or irritability. Leg
tremors, nausea and vomiting and an urge to bear down also are common.
, During the second stage of labor, assessment would include which of the following?
a. Complaints of rectal or perineal pressure
b. Estimated date of birth
c. Fundal height
d. Fetal position - Answer-a. Complaints of rectal or perineal pressure
During the second stage of labor, the nurse would assess for signs typical for this stage,
such as complaints of rectal or perineal pressure. Assessment of estimated date of
birth, fundal height, and fetal position are assessments for the first stage of labor.
Stage 1 of labor includes which phases in the correct order?A. Transition, Latent, Active
B. Active, Latent, Active
C. Active, Transition, Latent
D. Latent, Active, Transition - Answer-D
In stage 1 of labor, during the active phase, the cervix dilates:
a. 0-6 cm
b. 7-9 cm
c. 6-8 cm
d. 8-10 cm - Answer-c
latent: 0-6 cm
active: 6-8 cm
transitional: 8-10 cm
Your laboring patient has transitioned to stage 2 of labor. What changes in the perineum
indicate the birth of the baby is imminent?
a. Increase in meconium-stained fluid and retracting perineum
b. Retracting perineum and anus with an increase of bloody show
c. Rapid and intense contractions
d. Bulging perineum and rectum with an increase in bloody show - Answer-d
an infant shows a tendency to bleed two days after birth. the nurse understands this is
most likely caused by which reason?
a. hemophilia
b. absence of intestinal bacteria and lack of vitamin k
c. an immature liver that is unable to synthesize clotting factors
d. delayed production of red blood cells - Answer-b
a primigravida diagnosed with type 1 diabetes mellitus reviews the insulin regimen with
the nurse. the nurse explains which changes in insulin requirements will occur in
pregnancy?
a. insulin requirements will increase during pregnancy and decrease after delivery
b. insulin. requirements will decrease during pregnancy and increase after delivery
