ATI RN
high risk labor and delivery nclex questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A gravida 2, para 1 is in active labor at 39 weeks gestation. Her cervical exam is 6 cm dilated, 60% effaced, and 0 station. An amniotomy is performed by the physician. The fluid is noted to be bloody and the fetal heart tones have decelerated to the 50s. What is the nurse’s next best action?
Correct Answer: A
Rationale: The correct answer is A: Notify the operating team of emergent cesarean delivery. Given the scenario of a gravida 2, para 1 in active labor with bloody fluid and fetal heart decelerations to the 50s following amniotomy, these signs indicate fetal distress. In this critical situation, immediate intervention with emergent cesarean delivery is necessary to prevent adverse outcomes for the baby. This step takes priority over other actions, as it ensures timely delivery and assessment of the fetus's well-being. Choices B, C, and D are not appropriate in this emergent situation as they do not directly address the fetal distress and the need for expedited delivery.
Question 5 of 5
When caring for a woman with a complete placenta previa, which finding should the nurse report to the physician?
Correct Answer: D
Rationale: The correct answer is D: O2 saturation less than 95%. In placenta previa, the placenta covers the cervix, increasing the risk of bleeding. Decreased oxygen saturation can indicate poor perfusion due to bleeding, necessitating immediate medical attention. A: BP of 95/60 is relatively normal and not an urgent concern in this scenario. B: Temperature of 100.1°F may indicate an infection but is not directly related to placenta previa. C: Urine output of 40 mL/hour is within the normal range and does not directly impact the management of placenta previa.