high risk labor and delivery nclex questions

high risk labor and delivery nclex questions Related

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The nurse is caring for a gravida 5, para 4 who has been 5 centimeters dilated for 2 hours. The uterine contractions are every 5 minutes and mild to palpation. Which is the most appropriate nursing action?

  • A. Administer ordered IV pain medicine
  • B. Assist the patient with frequent position changes
  • C. Prepare patient for epidural anesthesia
  • D. Prepare patient for a cesarean section delivery
Correct Answer: B

Rationale: The correct answer is B: Assist the patient with frequent position changes. This is the most appropriate nursing action because the patient is already in active labor (5 cm dilated), experiencing regular contractions, and has mild pain. Encouraging position changes can help progress labor by promoting optimal fetal positioning and descent, relieving pressure on the cervix, and enhancing uterine contractions. This can potentially shorten labor duration and reduce the risk of complications. Administering IV pain medicine (choice A) is not necessary at this stage as the pain is mild. Preparing for epidural anesthesia (choice C) is premature for mild pain and can slow down labor. Preparing for a cesarean section delivery (choice D) is not indicated at this point as the patient is progressing in labor.

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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,

An infant was born 1 minute ago and the Apgar score is being assigned. The infant has blue extremities, minimal flexion, a weak cry, a heart rate of 110 beats per minute, and coughs and pulls away when suctioned. How many points should be assigned? Record your answer using a whole number:

  • A. 3
  • B. 2
  • C. 1
Correct Answer: A

Rationale: The correct answer is A (3 points). The Apgar score assesses newborns' overall health shortly after birth. Each category (appearance, pulse, grimace, activity, and respiration) is scored from 0 to 2. In this case, the infant exhibits central cyanosis (blue extremities), weak muscle tone (minimal flexion), a weak cry, a heart rate of 110 bpm (slightly below normal), and responsive to suctioning (coughs, pulls away) indicating some respiratory effort. Therefore, the infant would receive 1 point for appearance (cyanosis), 1 point for pulse (110 bpm), 1 point for grimace (weak cry), totaling 3 points. Choices B, C, and D are incorrect as they do not accurately reflect the infant's condition and Apgar scoring criteria.

When caring for a woman with a complete placenta previa, which finding should the nurse report to the physician?

  • A. BP of 95/60
  • B. Temperature of 100.1°F
  • C. Urine output of 40 mL/hour
  • D. O2 saturation less that 95%
Correct Answer: D

Rationale: The correct answer is D: O2 saturation less than 95%. In placenta previa, the placenta covers the cervix, increasing the risk of bleeding. Decreased oxygen saturation can indicate poor perfusion due to bleeding, necessitating immediate medical attention. A: BP of 95/60 is relatively normal and not an urgent concern in this scenario. B: Temperature of 100.1°F may indicate an infection but is not directly related to placenta previa. C: Urine output of 40 mL/hour is within the normal range and does not directly impact the management of placenta previa.

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.

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.

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