Intrapartum NCLEX questions & Answers 2022| Complete Solution With Rationale
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Intrapartum NCLEX
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Intrapartum NCLEX
Intrapartum NCLEX questions & Answers 2022| Complete Solution With Rationale
1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted?
A.The client begins to expel clear vaginal fluid
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intrapartum nclex questions amp answers 2022| complete solution with rationale 1a nurse is caring for a client in labor the nurse determines that the client is beginning in the 2nd stage of labor
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Intrapartum NCLEX questions & Answers 2022| Complete
Solution With Rationale
1.A nurse is caring for a client in labor. The nurse determines that the client is
beginning in the 2nd stage of labor when which of the following assessments is
noted?
A.The client begins to expel clear vaginal fluid
B.The contractions are regular
C.The membranes have ruptured
D.The cervix is dilated completely
1.4. The second stage of labor begins when the cervix is dilated completely and ends
with the birth of the neonate.
A nurse in the labor room is caring for a client in the active phases of labor. The
nurse is assessing the fetal patterns and notes a late deceleration on the monitor
strip. The most appropriate nursing action is to:
1.Place the mother in the supine position
2.Document the findings and continue to monitor the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV infusion
3. Late decelerations are due to uteroplacental insufficiency as the result of decreased
blood flow and oxygen to the fetus during the uterine contractions. This causes
hypoxemia; therefore oxygen is necessary. The supine position is avoided because it
decreases uterine blood flow to the fetus. The client should be turned to her side to
displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin
infusion is discontinued when a late deceleration is noted.
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
physician?
1.Fetal heart rate of 180 beats per minute
2.White blood cell count of 12,000
3.Maternal pulse rate of 85 beats per minute
4.Hemoglobin of 11.0 g/dL
1. A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per
minute could indicate fetal distress and would warrant physician notification. By full
term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution
caused by an increase in plasma volume during pregnancy.
A client in labor is transported to the delivery room and is prepared for a
cesarean delivery. The client is transferred to the delivery room table, and the
nurse places the client in the:
1.Trendelenburg's position with the legs in stirrups
2.Semi-Fowler position with a pillow under the knees
,3.Prone position with the legs separated and elevated
4.Supine position with a wedge under the right hip
4. Vena cava and descending aorta compression by the pregnant uterus impedes blood
return from the lower trunk and extremities. This leads to decreasing cardiac return,
cardiac output, and blood flow to the uterus and the fetus. The best position to prevent
this would be side-lying with the uterus displaced off of abdominal vessels. Positioning
for abdominal surgery necessitates a supine position; however, a wedge placed under
the right hip provides displacement of the uterus.
. A nurse is caring for a client in labor and prepares to auscultate the fetal heart
rate by using a Doppler ultrasound device. The nurse most accurately determines
that the fetal heart sounds are heard by:
1.Noting if the heart rate is greater than 140 BPM
2.Placing the diaphragm of the Doppler on the mother abdomen
3.Performing Leopold's maneuvers first to determine the location of the fetal
heart
4.Palpating the maternal radial pulse while listening to the fetal heart rate
4. The nurse simultaneously should palpate the maternal radial or carotid pulse and
auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart
rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate.
Leopold's maneuvers may help the examiner locate the position of the fetus but will not
ensure a distinction between the two rates.
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to
stimulate uterine contractions. Which assessment finding would indicate to the
nurse that the infusion needs to be discontinued?
1.Three contractions occurring within a 10-minute period
2.A fetal heart rate of 90 beats per minute
3.Adequate resting tone of the uterus palpated between contractions
4.Increased urinary output
2. A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable
decelerations indicate fetal distress and the need to discontinue to pitocin. The goal of
labor augmentation is to achieve three good-quality contractions in a 10-minute period.
A nurse is beginning to care for a client in labor. The physician has prescribed an
IV infusion of Pitocin. The nurse ensures that which of the following is
implemented before initiating the infusion?
1.Placing the client on complete bed rest
2.Continuous electronic fetal monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the client's bedside
2. Continuous electronic fetal monitoring should be implemented during an IV infusion of
Pitocin.
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 BPM. Which of the following nursing
,actions is most appropriate?
1.Encourage the client's coach to continue to encourage breathing exercises
2.Encourage the client to continue pushing with each contraction
3.Continue monitoring the fetal heart rate
4.Notify the physician or nurse mid-wife
4. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between
contractions may indicate the need for immediate medical management, and the
physician or nurse mid-wife needs to be notified.
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 of the following actions is most
appropriate?
1.Document the findings and tell the mother that the monitor indicates fetal well-
being
2.Take the mothers vital signs and tell the mother that bed rest is required to
conserve oxygen.
3.Notify the physician or nurse mid-wife of the findings.
4.Reposition the mother and check the monitor for changes in the fetal tracing
1. Accelerations are transient increases in the fetal heart rate that often accompany
contractions or are caused by fetal movement. Episodic accelerations are thought to be
a sign of fetal-well being and adequate oxygen reserve.
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 monitor,
the initial nursing assessment is which of the following?
1.Identifying the types of accelerations
2.Assessing the baseline fetal heart rate
3.Determining the frequency of the contractions
4.Determining the intensity of the contractions
2. Assessing the baseline fetal heart rate is important so that abnormal variations of the
baseline rate will be identified if they occur.
Options 1 and 3 are important to assess, but not as the first priority.
A nurse is reviewing the record of a client in the labor room and notes that the
nurse midwife has documented that the fetus is at -1 station. The nurse
determines that the fetal presenting part is:
1.1 cm above the ischial spine
2.1 fingerbreadth below the symphysis pubis
3.1 inch below the coccyx
4.1 inch below the iliac crest
1. Station is the relationship of the presenting part to an imaginary line drawn between
the ischial spines, is measured in centimeters, and is noted as a negative number
, above the line and a positive number below the line. At -1 station, the fetal presenting
part is 1 cm above the ischial spines.
A pregnant client is admitted to the labor room. An assessment is performed, and
the nurse notes that the client's hemoglobin and hematocrit levels are low,
indicating anemia. The nurse determines that the client is at risk for which of the
following?
1.A loud mouth
2.Low self-esteem
3.Hemorrhage
4.Postpartum infections
4. Anemic women have a greater likelihood of cardiac decompensation during labor,
postpartum infection, and poor wound healing. Anemia does not specifically present a
risk for hemorrhage. Having a loud mouth is only related to the person typing up this
test.
A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the
nurse observes the umbilical cord lengthen and a spurt of blood from the vagina.
The nurse documents these observations as signs of:
1.Hematoma
2.Placenta previa
3.Uterine atony
4.Placental separation
4. As the placenta separates, it settles downward into the lower uterine segment. The
umbilical cord lengthens, and a sudden trickle or spurt of blood appears.
A client arrives at a birthing center in active labor. Her membranes are still intact,
and the nurse-midwife prepares to perform an amniotomy. A nurse who is
assisting the nurse-midwife explains to the client that after this procedure, she
will most likely have:
1.Less pressure on her cervix
2.Increased efficiency of contractions
3.Decreased number of contractions
4.The need for increased maternal blood pressure monitoring
2. Amniotomy can be used to induce labor when the condition of the cervix is favorable
(ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows
the fetal head to contact the cervix more directly and may increase the efficiency of
contractions.
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?
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