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. In the active phase of labor, the cervix is typically dilated from 6 to 10 cm. This phase marks the transition from early labor to active labor, where contractions become stronger and more frequent, leading to further cervical dilation for the eventual delivery of the baby. The other choices are incorrect because: A: Latent phase is typically from 0 to 6 cm dilation. C: Second stage refers to the stage of labor starting from full dilation (10 cm) until the baby is born. D: Third stage is the stage after the baby is born, focusing on the delivery of the placenta.
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 - White blood cell count of 28,000 mm3 postbirth. This finding indicates a possible infection or inflammation, which can be concerning after vaginal delivery. A high white blood cell count may suggest an ongoing infection that needs immediate attention. A: Estimated blood loss of 500 mL is within normal range for vaginal delivery and is not a cause for concern. C: Fingers tingling may be due to various reasons unrelated to the delivery process and is not a typical concern post vaginal delivery. D: Thirst is a common symptom post-delivery and is not indicative of a serious complication.
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, 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 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: 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 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. 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.