ATI RN
high risk labor and delivery nclex questions Questions
Question 1 of 5
A sterile vaginal examination completed on a patient revealed the presenting part to be the mentum. What is this presentation known as?
Correct Answer: A
Rationale: The correct answer is A: Face presentation. In this presentation, the mentum (chin) of the baby is the presenting part. This is a relatively rare presentation where the baby's head is extended, resulting in the face being the first part to be delivered. In a face presentation, the baby's head is hyperextended rather than flexed as in a vertex presentation. B: Breech presentation is when the baby's buttocks or feet are the presenting part. C: Vertex presentation is when the baby's head is the presenting part with the occiput leading the way. D: Shoulder presentation is when the baby's shoulder is the presenting part, which is a potentially dangerous situation requiring immediate medical intervention.
Question 2 of 5
Which of the following is a function of a doula during labor?
Correct Answer: D
Rationale: The correct answer is D. A doula provides nonpharmacological pain relief during labor by offering emotional support, comfort measures, breathing techniques, and massage. This helps the mother cope with labor pain naturally. Choices A and C involve medical interventions that are typically performed by healthcare providers. Choice B is the role of a healthcare professional trained in assessing fetal well-being.
Question 3 of 5
The nurse is caring for a 34-year-old gravida 4, para 3 experiencing a prolonged labor. The physician performed an amniotomy 3 hours ago to stimulate the progression of labor. The patient’s most recent vaginal exam was 8/80%/0. Which assessment finding should the nurse should be most concerned about?
Correct Answer: B
Rationale: The correct answer is B: FHR baseline of 165. A baseline FHR above 160 is considered tachycardia in labor, which could indicate fetal distress. This finding is concerning as it may suggest fetal hypoxia or other complications, requiring immediate attention to prevent adverse outcomes. The other options are less concerning: A: Pain score of 7/10 is subjective and expected during labor. C: Mild variable decelerations are common in labor and may not immediately indicate distress. D: Increased bloody mucous discharge is a normal finding post-amniotomy and not necessarily indicative of fetal distress.
Question 4 of 5
Which is the cervical exam that most indicates the use of misoprostol?
Correct Answer: A
Rationale: The correct answer is A: 1 cm dilated, 20% effaced, -3 station, firm and posterior. Misoprostol is commonly used for cervical ripening in preparation for labor induction. This choice indicates an unfavorable cervix, which would benefit from cervical ripening agents like misoprostol. The cervix is minimally dilated (1 cm), partially effaced (20%), high (-3 station), firm, and posterior. This profile suggests that the cervix is not yet ripe and may require assistance in ripening for labor induction. Choice B: 3-4 cm dilated, 50% effaced, -2 station, firm and midposition - this indicates a more favorable cervix for labor and would not typically require misoprostol for cervical ripening. Choice C: 5 cm dilated, 80% effaced, 0 station, soft and midposition - this indicates an even more favorable cervix for labor,
Question 5 of 5
The nurse is caring for a gravida 5, para 4 who has been 5 centimeters dilated for 2 hours. The uterine contractions are every 5 minutes and mild to palpation. Which is the most appropriate nursing action?
Correct Answer: B
Rationale: The correct answer is B: Assist the patient with frequent position changes. This is the most appropriate nursing action because the patient is already in active labor (5 cm dilated), experiencing regular contractions, and has mild pain. Encouraging position changes can help progress labor by promoting optimal fetal positioning and descent, relieving pressure on the cervix, and enhancing uterine contractions. This can potentially shorten labor duration and reduce the risk of complications. Administering IV pain medicine (choice A) is not necessary at this stage as the pain is mild. Preparing for epidural anesthesia (choice C) is premature for mild pain and can slow down labor. Preparing for a cesarean section delivery (choice D) is not indicated at this point as the patient is progressing in labor.