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. A baseline FHR above 160 is considered tachycardia in labor, which could indicate fetal distress. This finding is concerning as it may suggest fetal hypoxia or other complications, requiring immediate attention to prevent adverse outcomes. The other options are less concerning: A: Pain score of 7/10 is subjective and expected during labor. C: Mild variable decelerations are common in labor and may not immediately indicate distress. D: Increased bloody mucous discharge is a normal finding post-amniotomy and not necessarily indicative of fetal distress.
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 the most appropriate nursing action because the patient is already in active labor (5 cm dilated), experiencing regular contractions, and has mild pain. Encouraging position changes can help progress labor by promoting optimal fetal positioning and descent, relieving pressure on the cervix, and enhancing uterine contractions. This can potentially shorten labor duration and reduce the risk of complications. Administering IV pain medicine (choice A) is not necessary at this stage as the pain is mild. Preparing for epidural anesthesia (choice C) is premature for mild pain and can slow down labor. Preparing for a cesarean section delivery (choice D) is not indicated at this point as the patient is progressing in labor.
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 umbilical cord prolapse. At this stage, the presenting part of the baby is relatively high in the pelvis, increasing the likelihood of the cord slipping past and becoming compressed against the cervix during contractions. This can lead to decreased blood flow and oxygen supply to the baby, posing a serious risk. Choices A, C, and D are less likely to result in cord prolapse due to the lower station of the baby in the pelvis, reducing the chance of cord compression.
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. In this scenario, the presence of bloody amniotic fluid and fetal heart rate decelerations to the 50s indicate potential fetal distress. Given the critical nature of this situation, an emergent cesarean delivery should be considered to expedite delivery and prevent further compromise to the fetus. This decision is based on the principle of prioritizing fetal well-being in situations of acute distress. Options B, C, and D do not address the immediate need for prompt intervention to ensure the safety of the fetus in distress.
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, there is a risk of maternal hemorrhage, which can lead to decreased oxygen delivery to tissues. Reporting low O2 saturation is crucial as it indicates potential hypoxia, necessitating immediate intervention. Choice A (BP of 95/60) may be within normal limits. Choice B (Temperature of 100.1°F) can indicate infection but is not directly related to placenta previa. Choice C (Urine output of 40 mL/hour) may reflect renal function but is not the priority in this situation.