ATI RN
high risk labor and delivery nclex questions Questions
Question 1 of 5
A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with
Correct Answer: D
Rationale: The correct answer is D: umbilical cord compression. In a breech presentation, the baby's bottom or feet present first, increasing the risk of umbilical cord prolapse or compression. This can lead to fetal distress due to compromised blood flow and oxygen supply. Other choices are incorrect as breech presentation is not associated with more rapid labor (A), high risk of infection (B), or increased maternal perineal trauma (C). It is crucial to prioritize addressing umbilical cord compression in a breech presentation to prevent potential complications for the baby.
Question 2 of 5
If a notation on the patient’s health record states that the fetal position is LSP, this indicates that the
Correct Answer: C
Rationale: The correct answer is C because LSP stands for Left Sacrum Posterior, meaning the baby's back is on the left side of the mother's spine and facing towards her back. This position is common during the early stages of labor. Choice A is incorrect as it describes a different position, choice B is incorrect as it refers to a different quadrant, and choice D is incorrect as it describes a location in the abdomen, not the pelvis.
Question 3 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 4 of 5
The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Powers. The four Ps of childbirth are Powers, Passage, Passenger, and Psyche. Powers refer to the contractions of the uterus and the pushing efforts of the mother during labor. Passage involves the birth canal through which the baby passes. Passenger refers to the fetus and its position during labor. Psyche relates to the psychological aspects of labor. In this case, Powers directly interact during childbirth by facilitating the progress of labor. Passage, Position, and Passenger are important factors as well, but they do not directly interact during childbirth like Powers do.
Question 5 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