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. During true labor, the cervix begins to dilate and efface in preparation for childbirth. This process is a definitive sign of active labor. In contrast, the other choices are not definitive signs of true labor. Choice A is incorrect because pain decreasing when walking is not a specific indicator of true labor. Choice C, the fetal membranes rupturing, indicates the beginning of labor but is not the definitive sign. Choice D, the fetal head at –1 station, signifies the descent of the baby into the pelvis but does not confirm active labor.
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. 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 3 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 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 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.
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 an umbilical cord prolapse. At this stage, the presenting part of the baby is not well engaged in the pelvis, increasing the likelihood of the cord slipping down in front of the baby. This can lead to compression of the cord during labor, which is a serious obstetric emergency. Choice A is less likely as the baby is only at -1 station and not as far down in the pelvis. Choice C also has the baby at a higher station (-2) and more dilated, which may help secure the baby's position. Choice D is the least likely as the baby is fully engaged at 0 station, reducing the risk of cord prolapse.