high risk labor and delivery nclex questions

high risk labor and delivery nclex questions Related

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The clinical nurse educator is providing instruction to a group of new nurses during labor orientation. Which information regarding the factors that have a role in the initiation of labor should the educator include in this teaching session? (Select all that apply.)

  • A. Progesterone levels become higher than estrogen levels.
  • B. Natural oxytocin in conjunction with other substances plays a role
  • C. Stretching, pressure, and irritation of the uterus and cervix increase
  • D. The secretion of prostaglandins from the fetal membranes decreases.
Correct Answer: B

Rationale: Step 1: Natural oxytocin is a hormone that plays a crucial role in initiating labor by stimulating uterine contractions.
Step 2: Other substances like prostaglandins also contribute to the initiation of labor by promoting cervical ripening and uterine contractions.
Step 3: Therefore, the correct answer is B as it accurately reflects the role of natural oxytocin and other substances in the initiation of labor.
Summary:
A: Progesterone levels becoming higher than estrogen levels is not directly related to the initiation of labor.
C: While stretching, pressure, and irritation of the uterus and cervix can contribute to labor, they are not the primary factors in labor initiation.
D: The secretion of prostaglandins from the fetal membranes actually increases during labor to facilitate the process, so this statement is incorrect.

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Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?

  • A. Extension
  • B. Engagement
  • C. Internal rotation
  • D. External rotation
Correct Answer: B

Rationale: The correct answer is B: Engagement. Engagement occurs when the largest diameter of the fetal presenting part (usually the biparietal diameter of the fetal head) passes through the pelvic inlet. This marks the beginning of the descent of the fetal head into the pelvis in preparation for birth. Extension (A) refers to the movement of the fetal head as it passes through the birth canal. Internal rotation (C) is the movement of the fetal head to align with the maternal pelvis. External rotation (D) occurs as the fetal head exits the birth canal.

A sterile vaginal examination completed on a patient revealed the presenting part to be the mentum. What is this presentation known as?

  • A. Face presentation
  • B. Breech presentation
  • C. Vertex presentation
  • D. Shoulder presentation
Correct Answer: A

Rationale: The correct answer is A: Face presentation. In this presentation, the mentum (chin) is the presenting part. The chin is the prominent part of the face, making it a face presentation. In a face presentation, the fetus is in a position where the head is extended rather than flexed. This can lead to complications during delivery.

Summary:
B: Breech presentation - In breech presentation, the baby's buttocks or feet are the presenting part.
C: Vertex presentation - In vertex presentation, the baby's head is the presenting part with the chin tucked towards the chest.
D: Shoulder presentation - In shoulder presentation, the baby is positioned transversely in the uterus with one or both shoulders presenting first.

The nurse is caring for a 34-year-old gravida 4, para 3 experiencing a prolonged labor. The physician performed an amniotomy 3 hours ago to stimulate the progression of labor. The patient’s most recent vaginal exam was 8/80%/0. Which assessment finding should the nurse should be most concerned about?

  • A. Pain score of 7/10
  • B. FHR baseline of 165
  • C. Mild variable decelerations
  • D. Increased bloody mucous discharge
Correct Answer: B

Rationale: The correct answer is B: FHR baseline of 165. In this scenario, a FHR baseline of 165 is concerning as it is higher than the normal range (110-160 bpm) for a term fetus. This may indicate fetal distress or hypoxia, possibly due to cord compression or placental insufficiency. High baseline FHR can lead to fetal complications like acidosis or asphyxia. The other choices are less concerning: A is subjective and manageable, C indicates a common response to labor and is usually transient, and D is expected after amniotomy. Monitoring and addressing the abnormal FHR is crucial for fetal well-being.

A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor?

  • A. Latent phase
  • B. Active phase
  • C. Second stage
  • D. Third stage
Correct Answer: B

Rationale: The correct answer is B: Active phase. In the active phase of labor, the cervix is typically dilated from 6 to 10 cm. This phase marks the transition from early labor to active labor, where contractions become stronger and more frequent, leading to further cervical dilation for the eventual delivery of the baby. The other choices are incorrect because:
A: Latent phase is typically from 0 to 6 cm dilation.
C: Second stage refers to the stage of labor starting from full dilation (10 cm) until the baby is born.
D: Third stage is the stage after the baby is born, focusing on the delivery of the placenta.

A gravida 2, para 1 is in active labor at 39 weeks gestation. Her cervical exam is 6 cm dilated, 60% effaced, and 0 station. An amniotomy is performed by the physician. The fluid is noted to be bloody and the fetal heart tones have decelerated to the 50s. What is the nurse’s next best action?

  • A. Notify the operating team of emergent cesarean delivery
  • B. Assist the patient to left lateral position
  • C. Apply O2 at 10-12 L/min per nonrebreather
  • D. Administer an IV fluid bolus
Correct Answer: A

Rationale: The correct answer is A: Notify the operating team of emergent cesarean delivery. Given the scenario of a gravida 2, para 1 in active labor with bloody fluid and fetal heart decelerations to the 50s following amniotomy, these signs indicate fetal distress. In this critical situation, immediate intervention with emergent cesarean delivery is necessary to prevent adverse outcomes for the baby. This step takes priority over other actions, as it ensures timely delivery and assessment of the fetus's well-being. Choices B, C, and D are not appropriate in this emergent situation as they do not directly address the fetal distress and the need for expedited delivery.

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