ATI RN
high risk labor and delivery nclex questions Questions
Question 1 of 5
How should the nurse respect the rapid psychologic changes occurring in the fourth stage of labor?
Correct Answer: B
Rationale: The correct answer is B. In the fourth stage of labor, the nurse should respect the rapid psychologic changes by taking the lead from the parents regarding interruption of bonding. This is important because it allows the parents to establish a strong bond with their newborn without feeling pressured or rushed. By following the parents' cues, the nurse can support their emotional needs and facilitate a positive bonding experience. Choices A, C, and D are incorrect because they do not prioritize the parents' emotional needs and may disrupt the bonding process. Inviting the family to see the newborn (Choice A) may add stress to the situation. Asking multiple questions about taking pictures (Choice C) may be intrusive. Taking the newborn to the nursery (Choice D) may interfere with the bonding process and discourage parental involvement.
Question 2 of 5
The nurse is explaining the physiology of uterine contractions to a group of nursing students. Which statement best explains the maternal-fetal exchange of oxygen and waste products during a contraction?
Correct Answer: D
Rationale: The correct answer is D because maternal-fetal exchange of oxygen and waste products continues during uterine contractions unless placental functions are reduced. Contractions do not directly affect this exchange, so option A is incorrect. Option B is incorrect because blood pressure changes do not necessarily impact the exchange. Option C is incorrect because spiral arteries play a role in supplying blood to the placenta, but compression during contractions does not halt the exchange process.
Question 3 of 5
Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?
Correct Answer: B
Rationale: The correct answer is B: Engagement. Engagement occurs when the largest diameter of the fetal presenting part passes through the pelvic inlet, indicating the descent of the fetal head into the pelvis. This is a crucial step in labor progress as it signifies the baby's readiness for birth. A: Extension occurs during the second stage of labor when the baby's head passes through the birth canal. C: Internal rotation is the movement of the baby's head within the pelvis to align with the maternal pelvis. D: External rotation happens after the baby's head is delivered to allow for the shoulders to rotate for birth. In summary, engagement is the correct answer as it specifically refers to the largest diameter of the fetal presenting part passing the pelvic inlet, setting the stage for the progression of labor.
Question 4 of 5
Which physiologic event is the key indicator of the commencement of true labor?
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation and effacement. This is the key indicator of true labor as it signifies the physiological changes needed for the cervix to open and thin out, allowing the baby to pass through the birth canal. Bloody show (A) can be present in early labor but is not a definitive sign. Fetal descent (C) and regular uterine contractions (D) are important, but cervical changes are the most reliable indicator of true labor initiation.
Question 5 of 5
A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor?
Correct Answer: B
Rationale: The correct answer is B: Active phase. In the active phase of labor, the cervix is typically dilated from 6 to 10 cm. This phase marks the transition from early labor to active labor, where contractions become stronger and more frequent, leading to further cervical dilation for the eventual delivery of the baby. The other choices are incorrect because: A: Latent phase is typically from 0 to 6 cm dilation. C: Second stage refers to the stage of labor starting from full dilation (10 cm) until the baby is born. D: Third stage is the stage after the baby is born, focusing on the delivery of the placenta.