ATI RN
high risk labor and delivery nclex questions Questions
Question 1 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 (usually the biparietal diameter of the fetal head) passes through the pelvic inlet. This marks the beginning of the descent of the fetal head into the pelvis in preparation for birth. Extension (A) refers to the movement of the fetal head as it passes through the birth canal. Internal rotation (C) is the movement of the fetal head to align with the maternal pelvis. External rotation (D) occurs as the fetal head exits the birth canal.
Question 2 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. At 6 cm dilation, the active phase of labor begins, where cervical dilation accelerates. In this phase, contractions become stronger and closer together, promoting effacement and descent of the baby. The latent phase (choice A) occurs at 0-6 cm dilation, characterized by slower progress. The second stage (choice C) is when the baby is born, not based on cervical dilation. The third stage (choice D) is the delivery of the placenta, not determined by cervical dilation. Therefore, at 6 cm dilation, the patient is in the active phase of labor.
Question 3 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 are positioned to come out first, which can lead to potential umbilical cord compression during labor. This compression can compromise fetal oxygenation and circulation, posing a serious risk to the baby's well-being. The other choices are incorrect because a breech presentation is not typically associated with more rapid labor (choice A), a high risk of infection (choice B), or maternal perineal trauma (choice C). It is important for healthcare providers to be vigilant in monitoring for signs of umbilical cord compression in cases of breech presentation to ensure the safety of both the mother and baby.
Question 4 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 5 of 5
If a notation on the patient’s health record states that the fetal position is LSP, this indicates that the
Correct Answer: C
Rationale: The correct answer is C because LSP stands for Left Sacrum Posterior, indicating the baby's buttocks are in the left posterior quadrant of the pelvis. In this position, the baby's head will typically be in the right anterior quadrant of the pelvis. Choice A is incorrect as it describes the head in the right posterior quadrant. Choice B is incorrect as it describes the head in the left anterior quadrant. Choice D is incorrect as it describes the buttocks in the right upper quadrant of the abdomen, which is not related to the fetal position LSP.