Latest Version!! Labor & Delivery
Saunders NCLEX Exam Questions and
Answers |100% Correct| 2025/2026
A nurse is caring for a laboring woman who has just received an epidural for pain management.
She suddenly reports shortness of breath and chest pain. What is the priority nursing action?
...
Latest Version!! Labor & Delivery
Saunders NCLEX Exam Questions and
Answers |100% Correct| 2025/2026
A nurse is caring for a laboring woman who has just received an epidural for pain management.
She suddenly reports shortness of breath and chest pain. What is the priority nursing action?
Assess the woman's vital signs and oxygen saturation levels immediately, as these symptoms
could indicate a serious complication such as a pulmonary embolism or an allergic reaction.
During the admission assessment of a woman in labor, the nurse notes that the fetal heart rate is
180 beats per minute with variable decelerations. What are the appropriate nursing interventions
to perform at this time?
Reposition the woman to her left side, provide oxygen via a face mask, and notify the
healthcare provider, as these interventions may help improve fetal oxygenation.
A laboring patient is experiencing intense contractions and states she feels an urgent need to
push. The nurse performs a vaginal exam and finds that the cervix is fully dilated. What is the
best action for the nurse to take at this point?
Instruct the patient to pant or breathe through the contractions to prevent premature pushing
until the healthcare provider arrives.
A woman in active labor is concerned about the possibility of an episiotomy. What information
should the nurse provide to address her concerns?
1
, An episiotomy is not routinely performed unless necessary, and the healthcare provider will
assess the situation during delivery to decide if it is needed to prevent tearing or facilitate a safe
delivery.
During a prenatal visit, a woman expresses concern about excessive swelling in her feet and legs.
Which explanation should the nurse provide regarding this symptom?
Some swelling is common in pregnancy due to fluid retention and increased pressure from
the growing uterus; however, sudden swelling in the face or hands may indicate a need for
further evaluation for conditions like preeclampsia.
While caring for a postpartum patient who received a spinal block, the nurse observes a sudden
drop in blood pressure. What should be the nurse's immediate response?
Administer intravenous fluids and position the patient in a supine position to promote venous
return, and notify the healthcare provider.
A nurse is providing discharge education to a postpartum client who had a cesarean delivery.
Which statement by the client indicates a need for further teaching?
"I can start exercising vigorously as soon as I feel up to it."
A patient in labor is being monitored for fetal heart tones. The nurse notes that the fetal heart rate
is consistently below 110 beats per minute. What should the nurse do next?
Assess for potential causes of fetal bradycardia, such as uterine contractions or maternal
position, and notify the healthcare provider.
2
,A woman who is 39 weeks pregnant is scheduled for an induction of labor due to gestational
hypertension. What should the nurse assess before administering oxytocin?
Assess the fetal heart rate pattern and uterine activity, ensuring there are no signs of fetal
distress or contraindications to labor induction.
A nurse is caring for a patient in the second stage of labor who is experiencing severe back pain.
What comfort measures can the nurse provide to help alleviate this pain?
Encourage the patient to use counter-pressure on the lower back and suggest different
positions, such as the hands-and-knees position, which may relieve pressure on the spine.
After delivery, the nurse notes that the newborn has a high-pitched cry and is jittery. What
condition should the nurse suspect, and what should be the immediate nursing action?
These signs may indicate neonatal withdrawal or hypoglycemia. The nurse should assess the
newborn’s blood glucose level and initiate appropriate interventions.
During a prenatal education session, the nurse discusses the importance of recognizing labor
signs. Which statement by the participant indicates a correct understanding?
"I should call the hospital when my contractions are 5 minutes apart, lasting for 60 seconds,
for an hour."
A woman in labor is experiencing prolonged decelerations in fetal heart rate monitoring. What
interventions should the nurse consider to improve fetal heart rate patterns?
3
, Repositioning the mother to her side, administering intravenous fluids, and providing oxygen
to improve uteroplacental perfusion.
A postpartum patient is experiencing heavy bleeding 12 hours after a vaginal delivery. What is
the nurse's priority assessment?
Assess the firmness and position of the uterine fundus to determine if uterine atony is the
cause of the bleeding.
A laboring woman has been given an epidural for pain relief. How should the nurse monitor for
potential complications associated with epidural anesthesia?
Monitor the patient for signs of hypotension, decreased fetal heart rate variability, and any
neurological deficits, including motor weakness.
During a vaginal examination of a laboring patient, the nurse notes the presence of meconium-
stained amniotic fluid. What is the priority nursing intervention?
Prepare for potential neonatal resuscitation and notify the healthcare provider to plan for
delivery and immediate newborn assessment.
A postpartum woman expresses feelings of sadness and anxiety. What assessment should the
nurse conduct to determine if this is a normal emotional response or a sign of postpartum
depression?
Use a standardized screening tool, such as the Edinburgh Postnatal Depression Scale, to
assess the severity of the woman’s feelings and determine the need for further intervention.
4
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