Delights Test Banks
Updated NCLEX Test Bank: Labor & Birth (Maternal
Nursing) | 250+ NGN Questions & Detailed Rationales -
Maternity and Pediatric Nursing, 5th Edition by Ricci, Kyle,
Carman
,Delights Test Banks
Question 1
A laboring client is in the active phase of the first stage of labor. She reports
increasing pain, and her cervix is dilated to 6 cm. Which nursing
intervention is the priority?
A. Encourage the client to take deep, cleansing breaths
B. Provide an epidural per client request
C. Offer ice chips and apply a cool cloth
D. Teach the client about the second stage of labor
Rationale:
During the active phase of the first stage of labor (6–7 cm dilation),
contractions intensify and pain becomes more severe. Pain relief becomes a
priority. If the client requests an epidural and there are no
contraindications, this intervention should be initiated as it aligns with
client-centered care and promotes physiologic and emotional stability.
Reference: Ricci et al., Chapter 13: Pain Management in Labor
,Delights Test Banks
Question 2
A nurse is assessing a client in labor. The fetus is in a breech presentation.
What is the primary concern with this fetal position?
A. Prolonged second stage of labor
B. Umbilical cord prolapse
C. Precipitous delivery
D. Shoulder dystocia
Rationale:
Breech presentations increase the risk of umbilical cord prolapse because
the presenting part (buttocks or feet) does not fill the pelvis snugly,
allowing the cord to slip past.
Reference: Ricci et al., Chapter 13: Fetal Presentation
Question 3
A client is in the transition phase of labor. Which assessment finding
requires immediate intervention?
, Delights Test Banks
A. Client reports rectal pressure
B. Contractions every 1.5 minutes, lasting 90 seconds
C. Fetal heart rate decelerates to 90 bpm during contractions
D. Cervix is dilated 8 cm and fully effaced
Rationale:
Fetal heart rate decelerations into the 90s can indicate fetal distress.
Immediate interventions are required to restore fetal oxygenation.
Reference: Ricci et al., Chapter 13: Fetal Monitoring and Transition Phase
Question 4
A client in early labor is admitted to the unit. She is 3 cm dilated and
reports mild, irregular contractions. What phase of labor is this?
A. Latent phase of the first stage
B. Active phase of the first stage
C. Second stage of labor
D. Transition phase
Updated NCLEX Test Bank: Labor & Birth (Maternal
Nursing) | 250+ NGN Questions & Detailed Rationales -
Maternity and Pediatric Nursing, 5th Edition by Ricci, Kyle,
Carman
,Delights Test Banks
Question 1
A laboring client is in the active phase of the first stage of labor. She reports
increasing pain, and her cervix is dilated to 6 cm. Which nursing
intervention is the priority?
A. Encourage the client to take deep, cleansing breaths
B. Provide an epidural per client request
C. Offer ice chips and apply a cool cloth
D. Teach the client about the second stage of labor
Rationale:
During the active phase of the first stage of labor (6–7 cm dilation),
contractions intensify and pain becomes more severe. Pain relief becomes a
priority. If the client requests an epidural and there are no
contraindications, this intervention should be initiated as it aligns with
client-centered care and promotes physiologic and emotional stability.
Reference: Ricci et al., Chapter 13: Pain Management in Labor
,Delights Test Banks
Question 2
A nurse is assessing a client in labor. The fetus is in a breech presentation.
What is the primary concern with this fetal position?
A. Prolonged second stage of labor
B. Umbilical cord prolapse
C. Precipitous delivery
D. Shoulder dystocia
Rationale:
Breech presentations increase the risk of umbilical cord prolapse because
the presenting part (buttocks or feet) does not fill the pelvis snugly,
allowing the cord to slip past.
Reference: Ricci et al., Chapter 13: Fetal Presentation
Question 3
A client is in the transition phase of labor. Which assessment finding
requires immediate intervention?
, Delights Test Banks
A. Client reports rectal pressure
B. Contractions every 1.5 minutes, lasting 90 seconds
C. Fetal heart rate decelerates to 90 bpm during contractions
D. Cervix is dilated 8 cm and fully effaced
Rationale:
Fetal heart rate decelerations into the 90s can indicate fetal distress.
Immediate interventions are required to restore fetal oxygenation.
Reference: Ricci et al., Chapter 13: Fetal Monitoring and Transition Phase
Question 4
A client in early labor is admitted to the unit. She is 3 cm dilated and
reports mild, irregular contractions. What phase of labor is this?
A. Latent phase of the first stage
B. Active phase of the first stage
C. Second stage of labor
D. Transition phase
