high risk labor and delivery nclex questions

high risk labor and delivery nclex questions Related

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A 29-year-old gravida 1, para 0 woman who is 35 weeks pregnant is admitted to the labor and delivery unit. She states that there is fluid leaking from her vagina but she is not sure if it is urine. What should the nurse do to make the determination?

  • A. A nitrazine test is the most conclusive test.
  • B. Nitrazine paper changes from yellow to dark blue due to the acidic nature of amniotic fluid.
  • C. Ferning is more conclusive than nitrazine paper testing.
  • D. Note if there is fluid leaking from the perineal area.
Correct Answer: A

Rationale: The correct answer is A: A nitrazine test is the most conclusive test. The rationale for this is as follows:
1. Nitrazine test detects the pH level of the fluid. Amniotic fluid is alkaline while urine is acidic.
2. Amniotic fluid will turn the nitrazine paper blue, indicating a pH level greater than 6.5, while urine will not change the color significantly.
3. This test is reliable and can help differentiate between amniotic fluid and urine leakage.

Summary of other choices:
B: Although nitrazine paper changes color due to the acidic nature of amniotic fluid, it is not a comprehensive test on its own.
C: Ferning test is not commonly used in practice and may not be as reliable as the nitrazine test.
D: Noting if fluid is leaking from the perineal area does not provide a conclusive determination of whether it is amniotic fluid or urine.

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Which is the cervical exam that most indicates the use of misoprostol?

  • A. 1 cm dilated, 20% effaced, -3 station, firm and posterior
  • B. 3-4 cm dilated, 50% effaced, -2 station, firm and midposition
  • C. 5 cm dilated, 80% effaced, 0 station, soft and midposition
  • D. 6 cm dilated, 100% effaced, +1 station, soft and anterior
Correct Answer: A

Rationale: The correct answer is A: 1 cm dilated, 20% effaced, -3 station, firm and posterior. Misoprostol is commonly used for cervical ripening in preparation for labor induction. This choice indicates an unfavorable cervix, which would benefit from cervical ripening agents like misoprostol. The cervix is minimally dilated (1 cm), partially effaced (20%), high (-3 station), firm, and posterior. This profile suggests that the cervix is not yet ripe and may require assistance in ripening for labor induction.

Choice B: 3-4 cm dilated, 50% effaced, -2 station, firm and midposition - this indicates a more favorable cervix for labor and would not typically require misoprostol for cervical ripening.

Choice C: 5 cm dilated, 80% effaced, 0 station, soft and midposition - this indicates an even more favorable cervix for labor,

A primigravida has just been examined. The examination revealed engagement of the fetal head. The nurse is aware that this means which of the following?

  • A. The biparietal diameter of the fetal head is at the level of the ischial spines.
  • B. The biparietal diameter of the fetal head is at –2 station.
  • C. The fetal head is well flexed.
  • D. The fetal head is unable to pass under the pubic arch.
Correct Answer: A

Rationale: The correct answer is A because engagement of the fetal head means the widest part of the head (biparietal diameter) is at the level of the ischial spines, indicating the head has descended into the pelvis. Choice B is incorrect as -2 station refers to the presenting part being 2 cm above the ischial spines, not at the level. Choice C is incorrect because engagement does not necessarily mean the head is well flexed. Choice D is incorrect as the ability of the head to pass under the pubic arch is not determined solely by engagement.

When does the second stage of labor begin?

  • A. at birth
  • B. when the early phase ends
  • C. when the cervix is completely dilated and effaced
  • D. when pushing begins
Correct Answer: D

Rationale: The correct answer is D: when pushing begins. The second stage of labor begins when the cervix is fully dilated, and the mother starts pushing to deliver the baby. This stage ends with the birth of the baby. Option A is incorrect because the second stage begins after birth. Option B is incorrect as it refers to the transition phase, not the second stage. Option C is incorrect because the cervix being fully dilated and effaced marks the beginning of the second stage, not the end of it.

The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)

  • A. Powers
  • B. Passage
  • C. Position
  • D. Passenger
Correct Answer: A

Rationale: The correct answer is A: Powers. In obstetrics, the four Ps that interact during childbirth are Powers (contractions), Passage (birth canal), Passenger (fetus), and Psyche (mother's psychological state). Powers refer to the force generated by contractions to push the baby through the birth canal. Passage is the route the baby takes during birth. Passenger is the baby itself. Position is not one of the four Ps in childbirth. It is crucial for nurses in obstetrics to understand how these four Ps work together to facilitate a safe and successful delivery.

A laboring patient states to the nurse, "I have to push!” What is the next nursing action?

  • A. Contact the health care provider.
  • B. Examine the patient’s cervix for dilation.
  • C. Review with her how to bear down with contractions.
  • D. Ask her partner to support her head with each push.
Correct Answer: B

Rationale: The correct answer is B. Examining the patient's cervix for dilation is the next nursing action because it will help determine the progress of labor and assess if it is safe for the patient to push. Contacting the health care provider (choice A) may delay necessary interventions. Reviewing how to bear down (choice C) is important but assessing cervical dilation takes precedence. Asking the partner to support her head (choice D) is not a priority in this situation.

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