ATI RN
high risk labor and delivery nclex questions Questions
Question 1 of 5
A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor?
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 6 cm dilation, the active phase of labor begins, where cervical dilation accelerates. In this phase, contractions become stronger and closer together, promoting effacement and descent of the baby. The latent phase (choice A) occurs at 0-6 cm dilation, characterized by slower progress. The second stage (choice C) is when the baby is born, not based on cervical dilation. The third stage (choice D) is the delivery of the placenta, not determined by cervical dilation. Therefore, at 6 cm dilation, the patient is in the active phase of labor.
Question 2 of 5
Which assessment finding would cause a concern for a patient who had delivered vaginally?
Correct Answer: B
Rationale: The correct answer is B because a white blood cell count of 28,000 mm3 postbirth indicates a possible infection, such as endometritis, which is a common postpartum complication. Elevated WBC count is a sign of an inflammatory process or infection, requiring further investigation and treatment. A: EBL of 500 mL is within the normal range for a vaginal delivery and may not necessarily indicate a concern. C: Patient complaints of fingers tingling may suggest temporary nerve compression or positional discomfort, not a significant concern post vaginal delivery. D: Patient complaining of thirst is a common symptom and not necessarily indicative of a complication post vaginal delivery.
Question 3 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, indicating the baby's buttocks are in the left posterior quadrant of the pelvis. In this position, the baby's head will typically be in the right anterior quadrant of the pelvis. Choice A is incorrect as it describes the head in the right posterior quadrant. Choice B is incorrect as it describes the head in the left anterior quadrant. Choice D is incorrect as it describes the buttocks in the right upper quadrant of the abdomen, which is not related to the fetal position LSP.
Question 4 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 5 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. In obstetrics, the four Ps that interact during childbirth are Powers (contractions), Passage (birth canal), Passenger (fetus), and Psyche (mother's psychological state). Powers refer to the force generated by contractions to push the baby through the birth canal. Passage is the route the baby takes during birth. Passenger is the baby itself. Position is not one of the four Ps in childbirth. It is crucial for nurses in obstetrics to understand how these four Ps work together to facilitate a safe and successful delivery.