Labor and Delivery

*1. A nurse is caring for a client in labor.

The nurse determines that the client is
beginning the second stage of labor
when which of the following
assessments is noted?

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.
*2. 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.
3. Increase the rate of the oxytocin (Pitocin)
intravenous infusion.
4. Document the findings and continue to
monitor the fetal patterns.
*3. A nurse is performing an
assessment of a client who is
scheduled for a cesarean delivery.
Which assessment finding would
indicate a need to contact the health
care provider?
1. Hemoglobin of 11g/dL
2. Fetal heart rate of 180 beats/min
3. Maternal pulse rate of 85 beats/min
4. White blood count of 12,000/mm3
*4. A 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 -1 station.
This documented finding indicates that
the fetal presenting part is located in
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
*5. A client arrives at a birthing center in
active labor. Her membranes are still
intact, and the health care provider
prepares to perform an amniotomy. What
will the nurse relay to the client as the
most likely outcome of the amniotomy?
1. Less pressure on her cervix
2. Decreased number of contractions
3. Increased efficiency of contractions
4. The need for increased maternal blood
pressure monitoring
*6. A nurse is monitoring a client in labor. The
nurse suspects umbilical cord compression if
which of the following is noted on the external
monitor tracing during a contraction?

* 1. Variability
* 2. Accelerations
* 3. Early decelerations
* 4. Variable decelerations
*7. A client in labor is transported to the delivery
room and prepared for a cesarean delivery. After
the client is transferred to the delivery room
table, the nurse places her in :

* 1. Supine position with a wedge under the right hip

* 2. Trendelenburg’s position with the legs in stirrups
* 3. Prone position with the legs separated and
elevated
* 4. Semi-Fowler’s position with a pillow under the
knees
*8. The nurse has provided discharge instructions
to a client who delivered a healthy infant by
cesarean delivery. Which statement made by the
client indicates a need for further instructions?

* 1. “I will begin abdominal exercises immediately.”

* 2. “I will notify the physician if I develop a fever.”
* 3. “I will turn on my side and push up with my
arms to get out of bed.”
* 4. “I will lift nothing heavier than the newborn
infant for at least 2 weeks.”
*9. A nurse is monitoring a client in active
labor and notes that the client is having
contractions every 3 minutes that last 45
seconds. The nurse notes that the fetal heart
rate between contractions is 100 beats/min.
Which of the following actions is most
appropriate?
* 1. Notify the health care provider.
* 2. Continue monitoring the fetal heart rate.
* 3. Encourage the client to continue pushing with
each contraction.
* 4. Instruct the client’s coach to continue to
encourage breathing techniques.
*10. A nurse is caring for a client in labor and
is monitoring the fetal heart rate patterns.
The nurse notes the presence of episodic
accelerations on the electronic fetal monitor
tracing. Which action is most appropriate?
* 1. Notify the health care provider.
* 2. Reposition the mother and check the monitor for
changes in the fetal tracing
* 3. Take the mother’s vital signs and tell the mother
that bedrest is required to conserve oxygen.
* 4. Document the findings and tell the mother that
the pattern on the monitor indicates fetal well-being.
*11. A nurse is admitting a pregnant client to
the labor room and attaches an external
electronic fetal monitor to the client’s
abdomen. After attachment of the electronic
fetal monitor, what is the next nursing action?

* 1. Identify the types of accelerations.

* 2. Assess the baseline fetal heart rate.
* 3. Determine the intensity of the contractions.
* 4. Determine the frequency of the contractions.
*12. A nurse is reviewing true and false labor
signs with a multiparous client. The nurse
determines that the client understands the
signs of true labor if she makes which
statement?

* 1. “I won’t be in labor until my baby drops.”

* 2. “My contractions will be felt in my abdominal
area.”
* 3. “My contractions will not be as painful if I walk
around.”
* 4. “My contractions will increase in duration and
intensity.”
*13. Which assessment finding following an
amniotomy should be conducted first?

* 1. For cervical dilation

* 2. For bladder distention
* 3. The maternal blood pressure
* 4. The fetal heart rate pattern
*14. The nurse has been working with a laboring
client and notes that she has been pushing
effectively for 1 hour. What is the client’s
primary physiological need at this time?

*1. Ambulation
*2. Rest between contractions
*3. Change positions frequently
*4. Consume oral food and fluids
*15. The nurse is assisting a client undergoing
induction of labor at 41 weeks’ gestation. The
client’s contractions are moderate and occurring
every 2 to 3 minutes, with a duration of 60
seconds. An internal fetal heart rate monitor is in
place. The baseline fetal heart rate has been 120 to
122 beats/minute for the past hour. What is the
priority nursing action?
* 1. Notify the health care provider.
* 2. Discontinue the infusion of oxytocin.
* 3. Place oxygen on at 8 to 10L/minute via face mask.
* 4. Contact the client’s primary support person(s) if not
currently present.
*16. The nurse performs a vaginal examination
and determines that the fetus is in a sacrum
anterior position. The nurse draws which
conclusion from this assessment data?

* 1. The fetal sacrum is toward the maternal

symphysis pubis.
* 2. The fetal sacrum is toward the maternal sacrum.
* 3. The fetal face is toward the maternal sacrum.
* 4. The fetal face is toward the maternal symphysis
pubis.
*17. The client has been having contractions
every 5 minutes for 7 hours. Which factor
would the nurse use to determine if this is
true or false labor?

* 1. The cervix is effacing and dilating.

* 2. This is the client’s second baby.
* 3. The contractions are becoming more intense and
lasting longer.
* 4. The membranes have ruptured.
*18. Which of the following would be the
highest priority for the nurse who is caring for
the laboring client?

* 1. Pain relief measures that are offered are

acceptable to the client.
* 2. Involvement of the client’s partner with the labor
and delivery.
* 3. Monitoring of appropriate fluid intake.
* 4. Assessment of the fetal response to the labor.
*
*19. As labor progresses, the nurse expects to
assess that a client’s contractions are
becoming:

* 1. More intense, less frequent of longer duration.

* 2. More intense, more frequent of longer duration.
* 3. Constant in intensity, more frequent, and of
shorter duration.
* 4. Constant in intensity and frequency but of shorter
duration.
*20. The neonate is crying, pink except for blue
extremities, has flexed arms with clenched hands,
a heart rate of 154, and gags when the bulb
suction is used. The apgar score would
be__________.
*21. Which of the following nursing
observations would indicate a sign of
impending placental separation and
expulsion?

* 1. Steady trickle of blood with an unchanged cord

length.
* 2. No bleeding with lengthening of the cord.
* 3. Small gush of blood with lengthening of the cord.
* 4. Small gush of blood with an unchanged cord
length.
*
*22. The nurse who determines a laboring
client is anxious anticipates that this might
result in:

* 1. Rapid progression of labor.

* 2. Increased pain during labor.
* 3. No reliance on support person.
* 4. Need for episiotomy.
*23. Earlier in the day, the fetal heart rate
baseline was 140. It is now 170. An
explanation for this could be: (Select all that
apply)

* 1. Maternal fever.
* 2. Narcotic administration.
* 3. Fetal movement.
* 4. Utero-placental insufficiency.
* 5. Fetal distress.
*24. The nurse determines teaching has been
effective when a laboring client makes which
of the following statements?

* 1. “Effacement is the opening of the cervix.”

* 2. “My cervix will probably efface before it dilates
because this is my first pregnancy.”
* 3. “Effacement is measured from 0 to 10
centimeters.”
* 4. “My cervix will probably efface and dilate
simultaneously because this is my first pregnancy.”
*
*25. The client’s vaginal examination reveals;
3 centimeters dilated, 80% effaced, vertex at
-1 station. The woman is talkative and
appears excited. The nurse determines the
client to be in which stage and phase of
labor?

* 1. First stage, latent phase

* 2. First stage, active phase
* 3. Second stage, latent phase
* 4. Third stage, transition stage
*26. The nurse is planning to teach a class of
expectant parents about the cardinal
movements, or changes in position, that
occur as the fetus passes through the birth
canal. The nurse plans to teach the
positional changes in the sequence in which
they occur when the fetus is in a cephalic
presentation. Arrange the cardinal
movements into this sequence.
* 1. Expulsion
* 2. External rotation
* 3. Flexion
* 4. Internal rotation
* 5. Restitution
*
*27. Which statement would indicate to the nurse
that the laboring client needs further education?

* 1. “Because this is my first labor, I will need an

epidural.”
* 2. “Labor can be long and difficult sometimes.”
* 3. “I should keep taking at least ice chips
throughout labor.”
* 4. “My partner can help me stay relaxed and
focused.”
*28. The nurse anticipates that assessment of a
normal episiotomy immediately post-delivery is
most likely to reveal which of the following by the
nurse?

* 1. Gaping between the sutures.

* 2. Slight bruising
* 3. Pus coming from the sutures
* 4. Edema that makes the tissue look shiny
*
*29. Fourth-stage nursing care for a client with
an episiotomy includes which of the following
by the nurse? Select all that apply.

* 1. Application of ice beginning 4 hours after

delivery
* 2. Ice pack to the perineum for up to 60 minutes
per application.
* 3. Inspection every 15 minutes during the first hour
after birth.
* 4. Instructions to avoid intercourse for at least 12
weeks.
* 5. Ice packs to be applied for 20-30 minutes and
removed for at least 20 minutes.
*30. The nurse would formulate which of the
following as a general goal when developing
childbirth education classes for pregnant
women in the community?

* 1. Provide education for all pregnant clients.

* 2. Ensure a normal spontaneous vaginal delivery.
* 3. Assist clients to know what to expect during
labor.
* 4. Prepare the couple for any possible
complications.
*31. The nurse concludes that client teaching
has been effective when the laboring client’s
partner shouts, “She’s crowning!” as:

* 1. He first starts to see a little of the baby’s head.

* 2. The baby’s head recedes upward between
pushing contractions.
* 3. The perineum is thin and stretching around the
occiput.
* 4. The mouth and nose are being suctioned.
*32. The nurse notes on the antepartal history
that the pregnant client has an android
pelvis. The nurse concludes that this client is
at an increased risk for:

* 1. A prolonged labor.
* 2. Occiput posterior position.
* 3. Precipitous delivery.
* 4. Developing postpartum complications.
*33. The nurse determines teaching has been
effective when a client with a fetus in a frank
breech position says, “My baby’s hips are;

* 1. Flexed and the knees are flexed.”

* 2. Extended and the knees are flexed.”
* 3. Flexed and the knees are extended.”
* 4. Extended and the knees are extended.”
*34. The fetal head is determined to be
presenting in a position of complete
extension. The labor and delivery nurse
should anticipate a:

* 1. Precipitous labor and delivery.

* 2. Prolonged labor and possible cesarean delivery.
* 3. Normal labor and spontaneous vaginal delivery.
* 4. Forceps-assisted vaginal delivery.
*35. The pregnant client is 7 cm dilated, 100%
effaced, and a +1 station. The fetus is in a
face presentation. The nurse concludes that
client teaching has been effective when the
client’s husband states:

* 1. “Our baby will come out face first.”

* 2. “Our baby will come out facing one hip.”
* 3. “Our baby will come out buttocks first.”
* 4. “Our baby will come out with the back of the
head first.”
*