ATI RN
high risk labor and delivery nclex questions Questions
Question 1 of 5
The nurse is caring for a laboring patient with multiple family members in the room. How can the nurse address this situation?
Correct Answer: B
Rationale: The correct answer is B because having multiple family members in the room during labor can be overwhelming and hinder the progress of labor. It is important for the laboring person to have privacy, focus, and reduce stress for a smoother labor experience. Asking the family members to leave the room ensures a calm and supportive environment for the laboring person. Incorrect Choices: A: Educating the family about pain normalcy is helpful, but privacy and focus are more crucial during labor. C: Mentioning epidural may not be appropriate as it is the laboring person's decision and may not be the best option for everyone. D: Assuming the laboring person wants family in the room without considering their preference may not be the best approach for their comfort and progress in labor.
Question 2 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 3 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 4 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.
Question 5 of 5
A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with
Correct Answer: D
Rationale: The correct answer is D: umbilical cord compression. In a breech presentation, the baby's bottom or feet present first, increasing the risk of umbilical cord prolapse or compression. This can lead to fetal distress due to compromised blood flow and oxygen supply. Other choices are incorrect as breech presentation is not associated with more rapid labor (A), high risk of infection (B), or increased maternal perineal trauma (C). It is crucial to prioritize addressing umbilical cord compression in a breech presentation to prevent potential complications for the baby.