ATI RN
high risk labor and delivery nclex questions Questions
Question 1 of 5
A laboring patient states to the nurse, "I have to push!” What is the next nursing action?
Correct Answer: B
Rationale: The correct answer is B. Examining the patient's cervix for dilation is the next nursing action because it will help determine the progress of labor and assess if it is safe for the patient to push. Contacting the health care provider (choice A) may delay necessary interventions. Reviewing how to bear down (choice C) is important but assessing cervical dilation takes precedence. Asking the partner to support her head (choice D) is not a priority in this situation.
Question 2 of 5
The clinical nurse educator is providing instruction to a group of new nurses during labor orientation. Which information regarding the factors that have a role in the initiation of labor should the educator include in this teaching session? (Select all that apply.)
Correct Answer: B
Rationale: Step 1: Natural oxytocin is a hormone that plays a crucial role in initiating labor by stimulating uterine contractions. Step 2: Other substances like prostaglandins also contribute to the initiation of labor by promoting cervical ripening and uterine contractions. Step 3: Therefore, the correct answer is B as it accurately reflects the role of natural oxytocin and other substances in the initiation of labor. Summary: A: Progesterone levels becoming higher than estrogen levels is not directly related to the initiation of labor. C: While stretching, pressure, and irritation of the uterus and cervix can contribute to labor, they are not the primary factors in labor initiation. D: The secretion of prostaglandins from the fetal membranes actually increases during labor to facilitate the process, so this statement is incorrect.
Question 3 of 5
A 29-year-old gravida 1, para 0 woman who is 35 weeks pregnant is admitted to the labor and delivery unit. She states that there is fluid leaking from her vagina but she is not sure if it is urine. What should the nurse do to make the determination?
Correct Answer: A
Rationale: The correct answer is A: A nitrazine test is the most conclusive test. The rationale for this is as follows: 1. Nitrazine test detects the pH level of the fluid. Amniotic fluid is alkaline while urine is acidic. 2. Amniotic fluid will turn the nitrazine paper blue, indicating a pH level greater than 6.5, while urine will not change the color significantly. 3. This test is reliable and can help differentiate between amniotic fluid and urine leakage. Summary of other choices: B: Although nitrazine paper changes color due to the acidic nature of amniotic fluid, it is not a comprehensive test on its own. C: Ferning test is not commonly used in practice and may not be as reliable as the nitrazine test. D: Noting if fluid is leaking from the perineal area does not provide a conclusive determination of whether it is amniotic fluid or urine.
Question 4 of 5
An infant was born 1 minute ago and the Apgar score is being assigned. The infant has blue extremities, minimal flexion, a weak cry, a heart rate of 110 beats per minute, and coughs and pulls away when suctioned. How many points should be assigned? Record your answer using a whole number:
Correct Answer: A
Rationale: The correct answer is A: 3 points. Apgar scoring assesses the newborn's overall condition at 1 and 5 minutes after birth. In this case, the infant's Apgar score should be 3 because the baby displays signs of mild distress with blue extremities, weak cry, and minimal flexion. The heart rate of 110 BPM and response to suctioning indicate some normal function. Each category (color, heart rate, reflex irritability, muscle tone, and respiratory effort) can score up to 2 points, totaling 10 points. Blue extremities and weak cry correspond to 1 point each, while minimal flexion corresponds to 0 points. The heart rate (110 BPM) and response to suctioning indicate 2 points each, totaling 3 points. Therefore, the correct score is 3 points. Choices B, C, and D are incorrect as they do not accurately reflect the severity of the infant's condition based on the Apgar
Question 5 of 5
A primigravida has just been examined. The examination revealed engagement of the fetal head. The nurse is aware that this means which of the following?
Correct Answer: A
Rationale: The correct answer is A because engagement of the fetal head means the widest part of the head (biparietal diameter) is at the level of the ischial spines, indicating the head has descended into the pelvis. Choice B is incorrect as -2 station refers to the presenting part being 2 cm above the ischial spines, not at the level. Choice C is incorrect because engagement does not necessarily mean the head is well flexed. Choice D is incorrect as the ability of the head to pass under the pubic arch is not determined solely by engagement.