ATI RN
labor and delivery nclex questions Questions
Question 1 of 5
The nurse is assessing the duration of a patient’s labor contractions. Which method does the nurse implement to assess the duration of labor contractions?
Correct Answer: C
Rationale: The nurse implements method C, which involves assessing the duration of contractions from the beginning to the end of each contraction. Duration refers to how long each contraction lasts from the start of the tightening sensation until it subsides. This assessment helps the nurse monitor the progress of labor, determine the effectiveness of contractions in dilating the cervix, and identify any potential issues such as prolonged or insufficient contractions that may affect labor progression. Assessing the duration of contractions is a key component of monitoring the labor process and ensuring safe delivery for both the mother and the baby.
Question 2 of 5
A laboring patient asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement?
Correct Answer: B
Rationale: The peak of a contraction, also known as its highest point or intensity, is referred to as the acme. This is the stage during which the contraction reaches its maximum strength before gradually subsiding. By identifying the acme of the contraction, healthcare providers can better gauge the progress of labor and assess the intensity of contractions to determine the appropriate course of action for the laboring patient.
Question 3 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 4 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 5 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.