high risk labor and delivery nclex questions

high risk labor and delivery nclex questions Related

Review high risk labor and delivery nclex questions related questions and content

A 40-year-old G2, P1 woman is admitted to the labor and delivery unit with contractions 6 minutes apart. She is 36 weeks pregnant, has a history of placenta previa, and is currently experiencing moderate vaginal bleeding. What should the nurse be prepared to do?

  • A. Perform a vaginal examination to determine cervical dilation
  • B. Assist the health care provider to perform artificial rupture of the membranes
  • C. Initiate external fetal monitoring
  • D. Encourage patient to ambulate to intensify labor
Correct Answer: C

Rationale: The correct answer is C: Initiate external fetal monitoring. In this scenario, the patient is at 36 weeks of gestation with a history of placenta previa and moderate vaginal bleeding, indicating a high-risk situation. External fetal monitoring allows for continuous assessment of the fetal heart rate and uterine contractions, which is crucial for identifying signs of fetal distress or complications related to placenta previa. This monitoring can help guide timely interventions and decision-making to ensure the safety of the mother and baby. Performing a vaginal examination (A) may increase the risk of bleeding in cases of placenta previa. Artificial rupture of membranes (B) can also lead to increased bleeding and should be avoided in this situation. Encouraging ambulation (D) is not recommended due to the risk of exacerbating bleeding and potential complications.

You may also like to solve these questions

How should the nurse respect the rapid psychologic changes occurring in the fourth stage of labor?

  • A. Invite the family to come in and see the newborn.
  • B. Take the lead from the parents regarding interruption of the bonding.
  • C. Ask multiple questions about taking pictures of the newborn.
  • D. Take the newborn to the nursery to encourage the parents to rest.
Correct Answer: B

Rationale: The correct answer is B because in the fourth stage of labor, immediate postpartum bonding between parents and newborn is crucial. The nurse should respect the rapid psychologic changes by taking cues from the parents on how they want this bonding experience to unfold. This approach ensures that the parents are supported in establishing a strong emotional bond with their newborn, promoting a positive postpartum experience.

Choice A is incorrect because inviting the family in may not align with the parents' wishes for privacy during this intimate moment. Choice C is incorrect as asking multiple questions about taking pictures may be intrusive and disrupt the bonding process. Choice D is incorrect as separating the newborn from the parents can hinder bonding and may not align with current best practices in postpartum care.

Which of the following is a function of a doula during labor?

  • A. Administration of oral pain medications
  • B. Assess fetal heart rate
  • C. Perform vaginal examination with the mother’s permission
  • D. Provide nonpharmacological pain relief
Correct Answer: D

Rationale: The correct answer is D. A doula provides nonpharmacological pain relief during labor by offering emotional support, comfort measures, breathing techniques, and massage. This helps the mother cope with labor pain naturally. Choices A and C involve medical interventions that are typically performed by healthcare providers. Choice B is the role of a healthcare professional trained in assessing fetal well-being.

A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with

  • A. more rapid labor.
  • B. a high risk of infection.
  • C. maternal perineal traum
  • D. umbilical cord compression.
Correct Answer: D

Rationale: The correct answer is D: umbilical cord compression. In a breech presentation, the baby's bottom or feet present first, increasing the risk of umbilical cord prolapse or compression. This can lead to fetal distress due to compromised blood flow and oxygen supply. Other choices are incorrect as breech presentation is not associated with more rapid labor (A), high risk of infection (B), or increased maternal perineal trauma (C). It is crucial to prioritize addressing umbilical cord compression in a breech presentation to prevent potential complications for the baby.

Which physiologic event is the key indicator of the commencement of true labor?

  • A. Bloody show
  • B. Cervical dilation and effacement
  • C. Fetal descent into the pelvic inlet
  • D. Uterine contractions every 7 minutes
Correct Answer: B

Rationale: The correct answer is B: Cervical dilation and effacement. This is the key indicator of true labor as it signifies the physiological changes needed for the cervix to open and thin out, allowing the baby to pass through the birth canal. Bloody show (A) can be present in early labor but is not a definitive sign. Fetal descent (C) and regular uterine contractions (D) are important, but cervical changes are the most reliable indicator of true labor initiation.

A woman who is 39 weeks pregnant presents to the labor and delivery unit stating that she thinks she is in labor. Her contractions are irregular at 7 to 10 minutes apart. Which sign is definitive for true labor?

  • A. Pain decreases when walking.
  • B. Cervical dilation is occurring.
  • C. The fetal membranes rupture.
  • D. The fetal head is at –1 station.
Correct Answer: B

Rationale: The correct answer is B: Cervical dilation is occurring. During true labor, the cervix begins to dilate and efface in preparation for childbirth. This process is a definitive sign of active labor. In contrast, the other choices are not definitive signs of true labor. Choice A is incorrect because pain decreasing when walking is not a specific indicator of true labor. Choice C, the fetal membranes rupturing, indicates the beginning of labor but is not the definitive sign. Choice D, the fetal head at –1 station, signifies the descent of the baby into the pelvis but does not confirm active labor.

Copyright © 2025 Nokea. All rights reserved.