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) is the presenting part. The chin is the prominent part of the face, making it a face presentation. In a face presentation, the fetus is in a position where the head is extended rather than flexed. This can lead to complications during delivery. Summary: B: Breech presentation - In breech presentation, the baby's buttocks or feet are the presenting part. C: Vertex presentation - In vertex presentation, the baby's head is the presenting part with the chin tucked towards the chest. D: Shoulder presentation - In shoulder presentation, the baby is positioned transversely in the uterus with one or both shoulders presenting first.
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: Provide nonpharmacological pain relief. A doula's role is to offer emotional support, comfort measures, and advocacy during labor. Providing nonpharmacological pain relief techniques such as massage, breathing exercises, and positioning is within the scope of a doula's practice. This helps the mother cope with labor discomfort without the use of medication. Choice A is incorrect because doulas do not administer medications. Choice B is incorrect as assessing fetal heart rate is typically done by healthcare providers. Choice C is incorrect as performing vaginal examinations is not a part of a doula's role.
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. In this scenario, a FHR baseline of 165 is concerning as it is higher than the normal range (110-160 bpm) for a term fetus. This may indicate fetal distress or hypoxia, possibly due to cord compression or placental insufficiency. High baseline FHR can lead to fetal complications like acidosis or asphyxia. The other choices are less concerning: A is subjective and manageable, C indicates a common response to labor and is usually transient, and D is expected after amniotomy. Monitoring and addressing the abnormal FHR is crucial for fetal well-being.
Question 4 of 5
Which is the cervical exam that most indicates the use of misoprostol?
Correct Answer: A
Rationale: Step 1: Misoprostol is a medication used for cervical ripening and induction of labor. Step 2: The characteristics of the cervix that indicate the need for misoprostol are early in the dilation process (1 cm dilated), minimally effaced (20%), high station (-3), and firm and posterior position. Step 3: Choice A best aligns with these characteristics, making it the correct answer. Step 4: Choices B, C, and D are more advanced in dilation, effacement, station, and cervical position which do not indicate the need for misoprostol.
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 because the patient is already 5cm dilated, indicating active labor. Position changes can help progress labor by promoting fetal descent and rotation. Administering pain medication (A) may not be necessary at this point as contractions are mild. Epidural anesthesia (C) may be considered later if requested by the patient. Cesarean section (D) is not indicated at this stage unless there are specific complications.