ATI RN
labor and delivery nclex questions Questions
Question 1 of 5
An increase in urinary frequency and leg cramps after the 36th week of pregnancy are an indication of
Correct Answer: A
Rationale: An increase in urinary frequency and leg cramps after the 36th week of pregnancy are common signs of "lightening." Lightening refers to the descent of the baby into the pelvis in preparation for labor. This shift in position can put pressure on the bladder, leading to increased urinary frequency. Additionally, the pressure on nerves and blood vessels in the pelvis can cause leg cramps. These symptoms are typically experienced in the final weeks of pregnancy and are considered normal signs that the body is preparing for labor.
Question 2 of 5
Which maternal factor may inhibit fetal descent during labor?
Correct Answer: A
Rationale: A full bladder can inhibit fetal descent during labor by obstructing the pathway for the baby to descend through the birth canal. A distended bladder can physically block the baby's head from moving down and putting pressure on the cervix, which is necessary for the progress of labor. It is important for pregnant individuals to empty their bladder regularly during labor to optimize the conditions for fetal descent and facilitate a smoother delivery process.
Question 3 of 5
Which assessment finding indicates that cervical dilation and/or effacement has occurred?
Correct Answer: C
Rationale: Bloody mucus drainage from the vagina, also known as "bloody show," is a common sign that indicates cervical dilation and/or effacement has occurred in anticipation of labor. This occurs as the mucus plug, which seals the cervix during pregnancy, is released as the cervix begins to soften, dilate, and efface in preparation for childbirth. This physical change in the cervix is a significant indicator that labor is approaching. The other options listed do not directly indicate cervical changes associated with labor progression like the presence of bloody mucus drainage does.
Question 4 of 5
The health care provider for a laboring patient makes the following entry into the patient’s record: 3/50%/+1. What instruction will the nurse implement with the patient?
Correct Answer: A
Rationale: The notation "3/50%/+" in the patient's record indicates that the patient is dilated 3 cm, the effacement is 50%, and the presenting part of the fetus is at +1 station. This information signifies that the patient is in active labor. The nurse should implement the instruction of having the patient remain in bed attached to the electronic fetal monitor to closely monitor the progression of labor and the well-being of the fetus. This will allow for continuous assessment and prompt interventions as needed.
Question 5 of 5
A patient asks the nurse how she can tell if labor is real. Which information should the nurse provide to this patient? (Select all that apply.)
Correct Answer: A
Rationale: Rationale: A) The correct answer is A) In true labor, the cervix begins to dilate. This is because cervical dilation is a key indicator of true labor progression. As labor begins and contractions become more regular and intense, the cervix starts to efface and dilate to allow the baby to move through the birth canal. This physiological change is a definitive sign that labor is indeed real. B) Option B is incorrect because the location of contractions alone cannot definitively determine if labor is real or false. While abdominal and groin contractions can be common in labor, the key factor is the progression of cervical dilation. C) Option C is incorrect as contractions in true labor typically become stronger and more frequent over time, unlike menstrual cramps which may not increase in intensity in a consistent pattern. Menstrual-like cramps can also occur in false labor, known as Braxton Hicks contractions. D) Option D is incorrect as true labor contractions typically become more regular, frequent, and intense as labor progresses. Inconsistent contractions in terms of frequency, duration, and intensity are more characteristic of false labor or prodromal labor. Educational Context: Understanding the signs of true labor is crucial for expectant mothers to differentiate between false labor and the real onset of labor. By recognizing the key indicators such as cervical dilation, women can better gauge when to seek medical attention and head to the hospital for delivery. This knowledge empowers mothers to make informed decisions about their labor experience and ensures timely and appropriate care during childbirth.