ATI RN
labor and delivery nclex questions Questions
Question 1 of 5
A laboring patient asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement?
Correct Answer: B
Rationale: The peak of a contraction, also known as its highest point or intensity, is referred to as the acme. This is the stage during which the contraction reaches its maximum strength before gradually subsiding. By identifying the acme of the contraction, healthcare providers can better gauge the progress of labor and assess the intensity of contractions to determine the appropriate course of action for the laboring patient.
Question 2 of 5
Which assessment finding indicates that cervical dilation and/or effacement has occurred?
Correct Answer: C
Rationale: Bloody mucus drainage from the vagina, also known as "bloody show," is a common sign that indicates cervical dilation and/or effacement has occurred in anticipation of labor. This occurs as the mucus plug, which seals the cervix during pregnancy, is released as the cervix begins to soften, dilate, and efface in preparation for childbirth. This physical change in the cervix is a significant indicator that labor is approaching. The other options listed do not directly indicate cervical changes associated with labor progression like the presence of bloody mucus drainage does.
Question 3 of 5
The health care provider for a laboring patient makes the following entry into the patient’s record: 3/50%/+1. What instruction will the nurse implement with the patient?
Correct Answer: A
Rationale: The notation "3/50%/+" in the patient's record indicates that the patient is dilated 3 cm, the effacement is 50%, and the presenting part of the fetus is at +1 station. This information signifies that the patient is in active labor. The nurse should implement the instruction of having the patient remain in bed attached to the electronic fetal monitor to closely monitor the progression of labor and the well-being of the fetus. This will allow for continuous assessment and prompt interventions as needed.
Question 4 of 5
A patient asks the nurse how she can tell if labor is real. Which information should the nurse provide to this patient? (Select all that apply.)
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
Which clinical finding should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.)
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.