Grade A+ Intrapartum NCLEX style questions and answers 2025
1. A nurse is caring for a client in 4. The second stage of labor begins when the cervix is
labor. The nurse determines that dilated completely and ends with the birth of the neonate.
the client is beginning in the 2nd
stage of labor when which of the
following assessments is noted?
1. The client begins to expel clear
vaginal fluid
2. The contractions are regular
3. The membranes have rup-
tured
4. The cervix is dilated completely
2. A nurse in the labor room is caring 3. Late decelerations are due to uteroplacental insuflcien-
for a client in the active phases cy as the result of decreased blood flow and oxygen to the
of labor. The nurse is assessing fetus during the uterine contractions. This causes hypox-
the fetal patterns and notes a late emia; therefore oxygen is necessary. The supine position
deceleration on the monitor strip. is avoided because it decreases uterine blood flow to the
The most appropriate nursing ac- fetus. The client should be turned to her side to displace
tion is to: pressure of the gravid uterus on the inferior vena cava. An
1. Place the mother in the supine intravenous
position
2. Document the findings and
continue to monitor the fetal pat-
terns
3. Administer oxygen via face
mask
4. Increase the rate of pitocin IV
infusion
3. A nurse is performing an assess- 1. A normal fetal heart rate is 120-160 beats per minute. A
ment of a client who is scheduled count of 180 beats per minute could indicate fetal distress
for a cesarean delivery. Which as- and would warrant physician notification. By full term,
, Grade A+ Intrapartum NCLEX style questions and answers 2025
sessment finding would indicate a a normal maternal hemoglobin range is 11-13 g/dL as
need to contact the physician? a result of the hemodilution caused by an increase in
1. Fetal heart rate of 180 beats per plasma volume during pregnancy.
minute
2. White blood cell count of
12,000
3. Maternal pulse rate of 85 beats
per minute
4. Hemoglobin of 11.0 g/dL
4. A client in labor is transported to 4. Vena cava and descending aorta compression by the
the delivery room and is prepared pregnant uterus impedes blood return from the lower
for a cesarean delivery. The client trunk and extremities. This leads to decreasing cardiac re-
is transferred to the delivery room turn, cardiac output, and blood flow to the uterus and the
table, and the nurse places the fetus. The best position to prevent this would be side-ly-
client in the: ing with the uterus displaced ott of abdominal vessels.
1. Trendelenburg's position with Positioning for abdominal surgery necessitates a supine
the legs in stirrups position; however, a wedge placed under the right hip
2. Semi-Fowler position with a pil- provides displacement of the uterus.
low under the knees
3. Prone position with the legs
separated and elevated
4. Supine position with a wedge
under the right hip
5. A nurse is caring for a client 4. The nurse simultaneously should palpate the maternal
in labor and prepares to auscul- radial or carotid pulse and auscultate the fetal heart rate
tate the fetal heart rate by us- to ditterentiate the two. If the fetal and maternal heart
ing a Doppler ultrasound device. rates are similar, the nurse may mistake the maternal heart
The nurse most accurately deter- rate for the fetal heart rate. Leopold's maneuvers may help
mines that the fetal heart sounds the examiner locate the position of the fetus but will not
are heard by: ensure a distinction between the two rates.
, Grade A+ Intrapartum NCLEX style questions and answers 2025
1. Noting if the heart rate is
greater than 140 BPM
2. Placing the diaphragm of the
Doppler on the mother abdomen
3.Performing Leopold's maneu-
vers first to determine the loca-
tion of the fetal heart
4.Palpating the maternal radial
pulse while listening to the fetal
heart rate
6. A nurse is caring for a client in la- 2. A normal fetal heart rate is 120-160 BPM. Bradycardia
bor who is receiving Pitocin by IV or late or variable decelerations indicate fetal distress and
infusion to stimulate uterine con- the need to discontinue to pitocin. The goal of labor aug-
tractions. Which assessment find- mentation is to achieve three good-quality contractions in
ing would indicate to the nurse a 10-minute period.
that the infusion needs to be dis-
continued?
1. Three contractions occurring
within a 10-minute period
2. A fetal heart rate of 90 beats per
minute
3. Adequate resting tone of the
uterus palpated between contrac-
tions
4. Increased urinary output
7. A nurse is beginning to care for 2. Continuous electronic fetal monitoring should be im-
a client in labor. The physician plemented during an IV infusion of Pitocin.
has prescribed an IV infusion of
Pitocin. The nurse ensures that
which of the following is imple-
1. A nurse is caring for a client in 4. The second stage of labor begins when the cervix is
labor. The nurse determines that dilated completely and ends with the birth of the neonate.
the client is beginning in the 2nd
stage of labor when which of the
following assessments is noted?
1. The client begins to expel clear
vaginal fluid
2. The contractions are regular
3. The membranes have rup-
tured
4. The cervix is dilated completely
2. A nurse in the labor room is caring 3. Late decelerations are due to uteroplacental insuflcien-
for a client in the active phases cy as the result of decreased blood flow and oxygen to the
of labor. The nurse is assessing fetus during the uterine contractions. This causes hypox-
the fetal patterns and notes a late emia; therefore oxygen is necessary. The supine position
deceleration on the monitor strip. is avoided because it decreases uterine blood flow to the
The most appropriate nursing ac- fetus. The client should be turned to her side to displace
tion is to: pressure of the gravid uterus on the inferior vena cava. An
1. Place the mother in the supine intravenous
position
2. Document the findings and
continue to monitor the fetal pat-
terns
3. Administer oxygen via face
mask
4. Increase the rate of pitocin IV
infusion
3. A nurse is performing an assess- 1. A normal fetal heart rate is 120-160 beats per minute. A
ment of a client who is scheduled count of 180 beats per minute could indicate fetal distress
for a cesarean delivery. Which as- and would warrant physician notification. By full term,
, Grade A+ Intrapartum NCLEX style questions and answers 2025
sessment finding would indicate a a normal maternal hemoglobin range is 11-13 g/dL as
need to contact the physician? a result of the hemodilution caused by an increase in
1. Fetal heart rate of 180 beats per plasma volume during pregnancy.
minute
2. White blood cell count of
12,000
3. Maternal pulse rate of 85 beats
per minute
4. Hemoglobin of 11.0 g/dL
4. A client in labor is transported to 4. Vena cava and descending aorta compression by the
the delivery room and is prepared pregnant uterus impedes blood return from the lower
for a cesarean delivery. The client trunk and extremities. This leads to decreasing cardiac re-
is transferred to the delivery room turn, cardiac output, and blood flow to the uterus and the
table, and the nurse places the fetus. The best position to prevent this would be side-ly-
client in the: ing with the uterus displaced ott of abdominal vessels.
1. Trendelenburg's position with Positioning for abdominal surgery necessitates a supine
the legs in stirrups position; however, a wedge placed under the right hip
2. Semi-Fowler position with a pil- provides displacement of the uterus.
low under the knees
3. Prone position with the legs
separated and elevated
4. Supine position with a wedge
under the right hip
5. A nurse is caring for a client 4. The nurse simultaneously should palpate the maternal
in labor and prepares to auscul- radial or carotid pulse and auscultate the fetal heart rate
tate the fetal heart rate by us- to ditterentiate the two. If the fetal and maternal heart
ing a Doppler ultrasound device. rates are similar, the nurse may mistake the maternal heart
The nurse most accurately deter- rate for the fetal heart rate. Leopold's maneuvers may help
mines that the fetal heart sounds the examiner locate the position of the fetus but will not
are heard by: ensure a distinction between the two rates.
, Grade A+ Intrapartum NCLEX style questions and answers 2025
1. Noting if the heart rate is
greater than 140 BPM
2. Placing the diaphragm of the
Doppler on the mother abdomen
3.Performing Leopold's maneu-
vers first to determine the loca-
tion of the fetal heart
4.Palpating the maternal radial
pulse while listening to the fetal
heart rate
6. A nurse is caring for a client in la- 2. A normal fetal heart rate is 120-160 BPM. Bradycardia
bor who is receiving Pitocin by IV or late or variable decelerations indicate fetal distress and
infusion to stimulate uterine con- the need to discontinue to pitocin. The goal of labor aug-
tractions. Which assessment find- mentation is to achieve three good-quality contractions in
ing would indicate to the nurse a 10-minute period.
that the infusion needs to be dis-
continued?
1. Three contractions occurring
within a 10-minute period
2. A fetal heart rate of 90 beats per
minute
3. Adequate resting tone of the
uterus palpated between contrac-
tions
4. Increased urinary output
7. A nurse is beginning to care for 2. Continuous electronic fetal monitoring should be im-
a client in labor. The physician plemented during an IV infusion of Pitocin.
has prescribed an IV infusion of
Pitocin. The nurse ensures that
which of the following is imple-
