ATI RN
high risk labor and delivery nclex questions Questions
Question 1 of 5
A woman who is 39 weeks pregnant presents to the labor and delivery unit stating that she thinks she is in labor. Her contractions are irregular at 7 to 10 minutes apart. Which sign is definitive for true labor?
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation is occurring. This is a definitive sign of true labor as it indicates that the cervix is opening up in preparation for childbirth. Contractions alone may not always indicate true labor, especially if they are irregular. Pain decreasing when walking (choice A) is not a definitive sign of true labor. The fetal membranes rupturing (choice C) is a sign of labor but not definitive on its own. The fetal head at –1 station (choice D) can indicate descent but is not as definitive as cervical dilation.
Question 2 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 3 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 4 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.
Question 5 of 5
The patient with which vaginal exam is most at risk for an umbilical cord prolapse?
Correct Answer: B
Rationale: The correct answer is B because a patient who is 5 cm dilated, 60% effaced, and at -3 station is most at risk for umbilical cord prolapse. At this stage, the presenting part of the baby is relatively high in the pelvis, increasing the likelihood of the cord slipping past and becoming compressed against the cervix during contractions. This can lead to decreased blood flow and oxygen supply to the baby, posing a serious risk. Choices A, C, and D are less likely to result in cord prolapse due to the lower station of the baby in the pelvis, reducing the chance of cord compression.