Exam (elaborations)
Labor and Birth NCLEX Questions 2025
- Course
- Labor and Birth NCLEX
- Institution
- Davis State University
Labor and Birth NCLEX Questions
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Labor and Birth NCLEX QuestionsStudy online at https://quizlet.com/_9fv185
1. The nurse is caring for a client in labor. Which assessment findings indicate
to the nurse that the client is beginning the second stage of labor? Select all
that apply.
1. The contractions are regular
2. The membranes have ruptured
3. The cervix is dilated completely
4. The client begins to expel clear vaginal fluid
5. The Ferguson reflex is initiated from perineal pressure: 3. The cervix is dilated
completely
5. The Ferguson reflex is initiated from perineal pressure
The second stage of labor begins when the cervix is dilated completely and ends
with birth of the neonate. The woman has a strong urge to push in stage 2 when
the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment
findings of the second stage of labor and occur in stage 1.
2. The nurse in the labor room is caring for a client in the active stage of
the first phase of labor. The nurse is assessing the fetal patterns and notes
a late deceleration on the monitor strip. What is the most appropriate nursing
action?
1. Administer oxygen via face mask
2. Place the mother in a supine position
3. Increase the rate of the oxytocin intravenous infusion
4. Document the findings and continue to monitor the fetal patterns: 1. Admin-
ister oxygen via face mask
Late decelerations are due to uteroplacental insufficiency and occur because of
decreased blood flow and oxygen to the fetus during the uterine contractions.
Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The
supine position is avoided because it decreases uterine blood flow to the fetus.
The client should be turned onto her side to displace pressure of the gravid uterus
on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a
late deceleration is noted. The oxytocin would cause further hypoxemia because of
increased uteroplacental insufficiency resulting from stimulation of contractions by
this medication. Although the nurse would document the occurrence, option 4 would
delay necessary treatment.
3. The nurse is performing an assessment of a client who is scheduled for
a cesarean delivery at 39 weeks of gestation. Which assessment finding
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, Labor and Birth NCLEX Questions
Study online at https://quizlet.com/_9fv185
indicates the need to contact the primary health care provider?
1. Hemoglobin of 11 g/dL
2. Fetal heart rate of 180 beats per minute
3. Maternal pulse rate of 85 beats per minute
4. White blood cell count of 12,000: 2. Fetal heart rate of 180 beats per minute
A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of
180 beats per minute could indicate fetal distress and would warrant immediate
notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to
13 g/dL because of the hemodilution caused by an increase in plasma volume during
pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats per
minute over pre-pregnancy readings to facilitated increased cardiac output, oxygen
transport, and kidney filtration. White blood cell counts in a normal pregnancy begin
to increase in the second trimester and peak in the third trimester, with a normal
range of 11,000-15,000.
4. A client arrives at a birthing center in active labor. After examination, it is
determined that her membranes are still intact and she is at a -2 station. The
primary health care provider prepares to perform an amniotomy. What will the
nurse relay to the client as the most likely outcomes of the amniotomy? Select
all that apply.
1. Less pressure on her cervix
2. Decreased number of contractions
3. Increased efficiency of contractions
4. The need for increased maternal blood pressure monitoring
5. The need for frequent fetal heart rate monitoring to detect the presence of
a prolapsed cord: 3. Increased efficiency of contractions
5. The need for frequent fetal heart rate monitoring to detect the presence of a
prolapsed cord
Amniotomy (artificial rupture of the membranes) can be used to induce labor when
the condition of the cervix is favorable (ripe) or to augment labor if the progress
begins to slow. Rupturing of the membranes allows the fetal head to contact the
cervix more directly and may increase the efficiency of contractions. Increased
monitoring or maternal blood pressure is unnecessary after this procedure. The fetal
heart rate needs to be monitored frequently, as there is an increased likelihood of a
prolapsed cord with ruptured membranes and a high presenting part.
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