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: Examine the patient’s cervix for dilation. This is the next nursing action because assessing cervical dilation is crucial in determining the progress of labor and if the patient is ready to push effectively. Contacting the health care provider (A) may cause unnecessary delays. Reviewing how to bear down with contractions (C) should be done after confirming cervical dilation. Asking her partner to support her head (D) is not the immediate 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: The correct answer is B: Natural oxytocin in conjunction with other substances plays a role in the initiation of labor. Oxytocin is a key hormone that stimulates uterine contractions during labor. Its release is crucial for the progression of labor. Other substances, such as prostaglandins, also play a role in initiating labor by softening the cervix and promoting contractions. Rationale: 1. Oxytocin is a well-known hormone that directly stimulates uterine contractions, leading to the initiation of labor. 2. Prostaglandins are also important in preparing the cervix for labor and promoting contractions, which contradicts option D. 3. Progesterone levels decreasing and estrogen levels increasing typically signal the onset of labor, which contradicts option A. 4. Factors like stretching, pressure, and irritation of the uterus and cervix are more related to the progression of labor rather than the initiation, which contradicts option C. In summary
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. The nurse should perform a nitrazine test to determine if the fluid leaking is amniotic fluid. Here's the rationale: 1. Nitrazine test is specifically designed to differentiate amniotic fluid from urine. 2. Amniotic fluid is alkaline, causing the nitrazine paper to turn blue when it comes into contact with it. 3. Urine, on the other hand, does not change the color of the nitrazine paper. 4. This test is quick, easy to perform, and provides a conclusive result in differentiating amniotic fluid from other fluids. In summary: - Choice B incorrectly describes the color change mechanism of nitrazine paper. - Choice C refers to ferning, which is not as conclusive as the nitrazine test. - Choice D does not provide a definitive method for determining if the leaking fluid is amniotic fluid.
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). The Apgar score assesses newborns' overall health shortly after birth. Each category (appearance, pulse, grimace, activity, and respiration) is scored from 0 to 2. In this case, the infant exhibits central cyanosis (blue extremities), weak muscle tone (minimal flexion), a weak cry, a heart rate of 110 bpm (slightly below normal), and responsive to suctioning (coughs, pulls away) indicating some respiratory effort. Therefore, the infant would receive 1 point for appearance (cyanosis), 1 point for pulse (110 bpm), 1 point for grimace (weak cry), totaling 3 points. Choices B, C, and D are incorrect as they do not accurately reflect the infant's condition and Apgar scoring criteria.
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: The biparietal diameter of the fetal head is at the level of the ischial spines. Engagement of the fetal head occurs when the largest transverse diameter of the presenting part (usually the biparietal diameter) reaches or passes through the pelvic inlet, specifically at the level of the ischial spines. This signifies descent of the fetal head into the maternal pelvis, indicating progress towards labor. Choice B (The biparietal diameter of the fetal head is at –2 station) is incorrect as station refers to the level of the presenting part in relation to the ischial spines, not engagement. Choice C (The fetal head is well flexed) is incorrect as engagement does not necessarily indicate the position of the fetal head. Choice D (The fetal head is unable to pass under the pubic arch) is incorrect as engagement actually signifies that the fetal head is in the optimal position to pass through the pelvis during labor.