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 - White blood cell count of 28,000 mm3 postbirth. This finding indicates a possible infection or inflammation, which can be concerning after vaginal delivery. A high white blood cell count may suggest an ongoing infection that needs immediate attention. A: Estimated blood loss of 500 mL is within normal range for vaginal delivery and is not a cause for concern. C: Fingers tingling may be due to various reasons unrelated to the delivery process and is not a typical concern post vaginal delivery. D: Thirst is a common symptom post-delivery and is not indicative of a serious complication.
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: Examine the patient’s cervix for dilation. This is the next nursing action because assessing cervical dilation is crucial in determining the progress of labor and if the patient is ready to push effectively. Contacting the health care provider (A) may cause unnecessary delays. Reviewing how to bear down with contractions (C) should be done after confirming cervical dilation. Asking her partner to support her head (D) is not the immediate 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. The four Ps of childbirth are Powers, Passage, Passenger, and Psyche. Powers refer to the contractions of the uterus and the pushing efforts of the mother during labor. Passage involves the birth canal through which the baby passes. Passenger refers to the fetus and its position during labor. Psyche relates to the psychological aspects of labor. In this case, Powers directly interact during childbirth by facilitating the progress of labor. Passage, Position, and Passenger are important factors as well, but they do not directly interact during childbirth like Powers do.
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: The correct answer is B: Natural oxytocin in conjunction with other substances plays a role in the initiation of labor. Oxytocin is a key hormone that stimulates uterine contractions during labor. Its release is crucial for the progression of labor. Other substances, such as prostaglandins, also play a role in initiating labor by softening the cervix and promoting contractions. Rationale: 1. Oxytocin is a well-known hormone that directly stimulates uterine contractions, leading to the initiation of labor. 2. Prostaglandins are also important in preparing the cervix for labor and promoting contractions, which contradicts option D. 3. Progesterone levels decreasing and estrogen levels increasing typically signal the onset of labor, which contradicts option A. 4. Factors like stretching, pressure, and irritation of the uterus and cervix are more related to the progression of labor rather than the initiation, which contradicts option C. In summary
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. The nurse should perform a nitrazine test to determine if the fluid leaking is amniotic fluid. Here's the rationale: 1. Nitrazine test is specifically designed to differentiate amniotic fluid from urine. 2. Amniotic fluid is alkaline, causing the nitrazine paper to turn blue when it comes into contact with it. 3. Urine, on the other hand, does not change the color of the nitrazine paper. 4. This test is quick, easy to perform, and provides a conclusive result in differentiating amniotic fluid from other fluids. In summary: - Choice B incorrectly describes the color change mechanism of nitrazine paper. - Choice C refers to ferning, which is not as conclusive as the nitrazine test. - Choice D does not provide a definitive method for determining if the leaking fluid is amniotic fluid.