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: The correct answer is A) In true labor, the cervix begins to dilate. This is because cervical dilation is a definitive sign of true labor progression. As labor advances, the cervix effaces (thins out) and dilates (opens up) to allow for the passage of the baby through the birth canal. This physical change in the cervix is a clear indicator that labor is indeed real. Option B) is incorrect because contractions felt in the abdomen and groin can occur in both true and false labor. Option C) is incorrect because although contractions in true labor can sometimes feel like menstrual cramps, this is not a definitive indicator. Option D) is incorrect because contractions in true labor should become more regular, longer, and stronger over time, rather than being inconsistent in frequency, duration, and intensity. Educationally, it is crucial for nurses to educate expectant mothers about the signs of true labor to help them differentiate between true and false labor. Understanding these signs can prevent unnecessary hospital visits and ease anxiety about the onset of labor. By explaining the physiological processes involved in labor, nurses empower patients to make informed decisions about when to seek medical attention.
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: In the third stage of labor, the separation of the placenta from the uterine wall is a crucial event. The correct answer, option C, states that the fundus descends below the umbilicus, which is indicative of placental separation. This descent occurs as the placenta detaches and is expelled from the uterus. Option A, a gush of blood appears, is incorrect because this is more likely to occur during the first stage of labor when the cervix dilates. Option B, the uterus rises upward in the abdomen, is incorrect as it is not a typical finding in the third stage of labor but may occur during contractions in the first and second stages. Option D, the cord descends further from the vagina, is incorrect as the descent of the cord does not directly indicate placental separation. Understanding these clinical findings is crucial for nurses to accurately assess the progress of labor and ensure proper management during the third stage. Educationally, this question helps reinforce the importance of recognizing key clinical signs of placental separation in the third stage of labor. Nurses must be knowledgeable about these signs to provide safe and effective care to both the mother and the newborn.