ATI RN
high risk labor and delivery nclex questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
What is a direct influence on cervical dilation? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A because the positioning of the pregnant person affects the alignment of the baby's head in the pelvis, directly influencing cervical dilation. Proper positioning helps the baby apply pressure to the cervix, promoting dilation. In contrast, the strength of uterine contractions (B) affects labor progress but not cervical dilation specifically. The length of time since ruptured membranes (C) may increase infection risk but does not directly impact dilation. Fetal presentation (D) affects the descent of the baby, not cervical dilation.
Question 5 of 5
What makes up the powers of labor and birth?
Correct Answer: A
Rationale: The correct answer is A (contractions and pushing efforts) because they are the main physiological components of labor and birth. Contractions help to thin and dilate the cervix, while pushing efforts help the baby descend through the birth canal. Pelvis and pelvic floor tissues (B) play a role in the mechanics of birth but do not make up the powers of labor. Fetal position, attitude, lie, and presentation (C) are important factors influencing labor progress but do not constitute the powers of labor. Oxytocin (D) is a hormone that stimulates contractions but is not a direct component of the powers of labor.