ATI RN
high risk labor and delivery nclex questions Questions
Question 1 of 5
Which assessment finding would cause a concern for a patient who had delivered vaginally?
Correct Answer: B
Rationale: The correct answer is B because a white blood cell count of 28,000 mm3 postbirth indicates a possible infection, such as endometritis, which is a common postpartum complication. Elevated WBC count is a sign of an inflammatory process or infection, requiring further investigation and treatment. A: EBL of 500 mL is within the normal range for a vaginal delivery and may not necessarily indicate a concern. C: Patient complaints of fingers tingling may suggest temporary nerve compression or positional discomfort, not a significant concern post vaginal delivery. D: Patient complaining of thirst is a common symptom and not necessarily indicative of a complication post vaginal delivery.
Question 2 of 5
A laboring patient states to the nurse, "I have to push!” What is the next nursing action?
Correct Answer: B
Rationale: The correct answer is B. Examining the patient's cervix for dilation is the next nursing action because it will help determine the progress of labor and assess if it is safe for the patient to push. Contacting the health care provider (choice A) may delay necessary interventions. Reviewing how to bear down (choice C) is important but assessing cervical dilation takes precedence. Asking the partner to support her head (choice D) is not a priority in this situation.
Question 3 of 5
The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Powers. In obstetrics, the four Ps that interact during childbirth are Powers (contractions), Passage (birth canal), Passenger (fetus), and Psyche (mother's psychological state). Powers refer to the force generated by contractions to push the baby through the birth canal. Passage is the route the baby takes during birth. Passenger is the baby itself. Position is not one of the four Ps in childbirth. It is crucial for nurses in obstetrics to understand how these four Ps work together to facilitate a safe and successful delivery.
Question 4 of 5
The clinical nurse educator is providing instruction to a group of new nurses during labor orientation. Which information regarding the factors that have a role in the initiation of labor should the educator include in this teaching session? (Select all that apply.)
Correct Answer: B
Rationale: Step 1: Natural oxytocin is a hormone that plays a crucial role in initiating labor by stimulating uterine contractions. Step 2: Other substances like prostaglandins also contribute to the initiation of labor by promoting cervical ripening and uterine contractions. Step 3: Therefore, the correct answer is B as it accurately reflects the role of natural oxytocin and other substances in the initiation of labor. Summary: A: Progesterone levels becoming higher than estrogen levels is not directly related to the initiation of labor. C: While stretching, pressure, and irritation of the uterus and cervix can contribute to labor, they are not the primary factors in labor initiation. D: The secretion of prostaglandins from the fetal membranes actually increases during labor to facilitate the process, so this statement is incorrect.
Question 5 of 5
A 29-year-old gravida 1, para 0 woman who is 35 weeks pregnant is admitted to the labor and delivery unit. She states that there is fluid leaking from her vagina but she is not sure if it is urine. What should the nurse do to make the determination?
Correct Answer: A
Rationale: The correct answer is A: A nitrazine test is the most conclusive test. The rationale for this is as follows: 1. Nitrazine test detects the pH level of the fluid. Amniotic fluid is alkaline while urine is acidic. 2. Amniotic fluid will turn the nitrazine paper blue, indicating a pH level greater than 6.5, while urine will not change the color significantly. 3. This test is reliable and can help differentiate between amniotic fluid and urine leakage. Summary of other choices: B: Although nitrazine paper changes color due to the acidic nature of amniotic fluid, it is not a comprehensive test on its own. C: Ferning test is not commonly used in practice and may not be as reliable as the nitrazine test. D: Noting if fluid is leaking from the perineal area does not provide a conclusive determination of whether it is amniotic fluid or urine.