MCN INTRAPARTUM
1. Administer oxygen via face mask.
1. A nursing student is assigned to care for a
client in labor. The nursing instructor asks
the student to describe fetal circulation,
specifically the ductus venosus. Which
statement is correct regarding the ductus
venosus?
1. Connects the pulmonary artery to the
aorta
2. Is an opening between the right and left
atria
3. Connects the umbilical vein to the
inferior vena cava
4. Connects the umbilical artery to the
inferior vena cava
3. Connects the umbilical vein to the inferior
vena cava
2. The nurse in a maternity unit is reviewing
the clients' records. Which client would
the nurse identify as being at the most risk
for developing disseminated intravascular
coagulation?
1. A primigravida with mild preeclampsia
2. A primigravida who delivered a 10-lb
infant 3 hours ago
3. A gravida II who has just been
diagnosed with dead fetus syndrome
4. A gravida IV who delivered 8 hours ago
and has lost 500 mL of blood
3. A gravida II who has just been diagnosed
with dead fetus syndrome
3. The nurse is caring for a client in labor.
Which assessment finding indicates to the
nurse that the client is beginning the
second stage of labor?
1. The contractions are regular.
2. The membranes have ruptured.
3. The cervix is dilated completely.
4. The client begins to expel clear vaginal
fluid.
3. The cervix is dilated completely.
4. The nurse in the labor room is caring for a
client in the active stage of the first phase
of labor. The nurse is assessing the fetal
patterns and notes a late deceleration on
the monitor strip. What is the most
appropriate nursing action?
2. Place the mother in a supine position.
3. Increase the rate of the oxytocin
(Pitocin) intravenous infusion.
4. Document the findings and continue to
monitor the fetal patterns.
1. Administer oxygen via face mask.
5. The nurse is performing an assessment of
a client who is scheduled for a cesarean
delivery. Which assessment finding would
indicate the need to contact the health
care provider?
1. Hemoglobin of 11 g/dL
2. Fetal heart rate of 180 beats/minute
3. Maternal pulse rate of 85 beats/minute
4. White blood cell count of 12,000
cells/mm3
2. Fetal heart rate of 180 beats/minute
6. The nurse is reviewing the record of a
client in the labor room and notes that the
health care provider has documented that
the fetal presenting part is at the –1
station. This documented finding indicates
that the fetal presenting part is located at
which area?
1. 1 inch below the coccyx
2. 1 inch below the iliac crest
3. 1 cm above the ischial spine
4. 1 fingerbreadth below the symphysis
pubis
3. 1 cm above the ischial spine
7. A client arrives at a birthing center in
active labor. Her membranes are still
intact, and the health care provider
prepares to perform an amniotomy. What
will the nurse relay to the client as
the most likely outcome of the
amniotomy?
1. Less pressure on her cervix
2. Decreased number of contractions
3. Increased efficiency of contractions
4. The need for increased maternal blood
pressure monitoring
3. Increased efficiency of contractions
8. The nurse is monitoring a client in labor.
The nurse suspects umbilical cord
compression if which is noted on the
external monitor tracing during a
contraction?
1. Variability
2. Accelerations
3. Early decelerations
4. Variable decelerations
4. Variable decelerations
9. A client in labor is transported to the
delivery room and prepared for a
cesarean delivery. After the client is
transferred to the delivery room table, the
nurse should place the client in which
position?
1. Supine position with a wedge under the
right hip
2. Trendelenburg's position with the legs
in stirrups
3. Prone position with the legs separated
and elevated
4. Semi-Fowler's position with a pillow
under the knees
1. Supine position with a wedge under the
right hip
10. The nurse is monitoring a client in active
labor and notes that the client is having
contractions every 3 minutes that last 45
seconds. The nurse notes that the fetal
heart rate between contractions is 100
beats/minute. Which nursing action
is most appropriate?
1. Notify the health care provider (HCP).
2. Continue monitoring the fetal heart rate.
3. Encourage the client to continue
pushing with each contraction.
4. Instruct the client's coach to continue to
encourage breathing techniques.
1. Notify the health care provider (HCP).
11. The nurse is caring for a client in labor
and is monitoring the fetal heart rate
patterns. The nurse notes the presence of
episodic accelerations on the electronic
fetal monitor tracing. Which action is most
appropriate?
1. Notify the health care provider of the
findings.
2. Reposition the mother and check the
monitor for changes in the fetal tracing.
3. Take the mother's vital signs and tell
the mother that bed rest is required to
conserve oxygen.
4. Document the findings and tell the
mother that the pattern on the monitor
indicates fetal well-being.
4. Document the findings and tell the mother
that the pattern on the monitor indicates fetal
well-being.
12. The nurse is admitting a pregnant client to
the labor room and attaches an external
electronic fetal monitor to the client's
abdomen. After attachment of the
electronic fetal monitor, what is
the next nursing action?
1. Identify the types of accelerations.
2. Assess the baseline fetal heart rate.
3. Determine the intensity of the
contractions.
4. Determine the frequency of the
contractions.
2. Assess the baseline fetal heart rate.
13. The nurse is reviewing true and false
labor signs with a multiparous client. The
nurse determines that the client
understands the signs of true labor if she
makes which statement?
1. "I won't be in labor until my baby
drops."
2. "My contractions will be felt in my
abdominal area."
3. "My contractions will not be as painful if
I walk around."
4. "My contractions will increase in
duration and intensity."
4. "My contractions will increase in duration
and intensity."
14. Which assessment finding following an
amniotomy should be conducted first?
1. Cervical dilation
2. Bladder distention
3. Fetal heart rate pattern
4. Maternal blood pressure
3. Fetal heart rate pattern
15. The nurse has been working with a
laboring client and notes that she has
been pushing effectively for 1 hour. What
is the client's primary physiological need
at this time?
1. Ambulation
2. Rest between contractions
3. Change positions frequently
4. Consume oral food and fluids
2. Rest between contractions
16. The nurse is assisting a client undergoing
induction of labor at 41 weeks' gestation.
The client's contractions are moderate
and occurring every 2 to 3 minutes, with a
duration of 60 seconds. An internal fetal
heart rate monitor is in place. The
baseline fetal heart rate has been 120 to
122 beats/minute for the past hour. What
is the priority nursing action?
1. Notify the health care provider.
2. Discontinue the infusion of oxytocin
(Pitocin).
3. Place oxygen on at 8 to 10 L/minute via
face mask.
4. Contact the client's primary support
person(s) if not currently present.
2. Discontinue the infusion of oxytocin
(Pitocin).
17. The nurse is assessing a pregnant client
in the second trimester of pregnancy who
was admitted to the maternity unit with a
suspected diagnosis of abruptio
placentae. Which assessment finding
should the nurse expect to note if this
condition is present?
1. Soft abdomen
2. Uterine tenderness
3. Absence of abdominal pain
4. Painless, bright red vaginal bleeding
2. Uterine tenderness
18. The maternity nurse is preparing for the
admission of a client in the third trimester
of pregnancy who is experiencing vaginal
bleeding and has a suspected diagnosis
of placenta previa. The nurse reviews the
health care provider's prescriptions and
should question which prescription?
1. Prepare the client for an ultrasound.
2. Obtain equipment for a manual pelvic
examination.
3. Prepare to draw a hemoglobin and
hematocrit blood sample.
4. Obtain equipment for external
electronic fetal heart rate monitoring.
2. Obtain equipment for a manual pelvic
examination.
19. An ultrasound is performed on a client at
term gestation who is experiencing
moderate vaginal bleeding. The results of
the ultrasound indicate that abruptio
placentae is present. On the basis of
these findings, the nurse should prepare
the client for which anticipated
prescription?
1. Delivery of the fetus
2. Strict monitoring of intake and output
3. Complete bed rest for the remainder of
the pregnancy
4. The need for weekly monitoring of
coagulation studies until the time of
delivery
1. Delivery of the fetus
20. The nurse is monitoring a client who is in
the active stage of labor. The client has
been experiencing contractions that are
short, irregular, and weak. The nurse
documents that the client is experiencing
which type of labor dystocia?
1. Hypotonic
2. Precipitous
3. Hypertonic
4. Preterm labor
1. Hypotonic
21. The nurse in a labor room is monitoring a
client with dysfunctional labor for signs of
fetal or maternal compromise. Which
assessment finding would alert the nurse
to a compromise?
1. Maternal fatigue
2. Coordinated uterine contractions
3. Progressive changes in the cervix
4. Persistent nonreassuring fetal heart
rate
4. Persistent nonreassuring fetal heart rate
22. The nurse in a labor room is preparing to 4. Administer oxygen, 8 to 10 L/minute, via
care for a client with hypertonic uterine face mask.
contractions. The nurse is told that the
client is experiencing uncoordinated 26. The nurse is performing an assessment
contractions that are erratic in their on a client diagnosed with placenta
frequency, duration, and intensity. What is previa. Which of these assessment
the priority nursing action? findings would the nurse expect to
1. Provide pain relief measures. note? Select all that apply.
2. Prepare the client for an amniotomy. 1. Uterine rigidity
3. Promote ambulation every 30 minutes. 2. Uterine tenderness
4. Monitor the oxytocin (Pitocin) infusion 3. Severe abdominal pain
closely. 4. Bright red vaginal bleeding
5. Soft, relaxed, nontender uterus
1. Provide pain relief measures. 6. Fundal height may be greater than
expected for gestational age.
23. The nurse is reviewing the health care o 4. Bright red vaginal bleeding
provider's (HCP's) prescriptions for a o 5. Soft, relaxed, nontender uterus
o 6. Fundal height may be greater than
client admitted for premature rupture of
expected for gestational age.
the membranes. Gestational age of the
27. The nurse in a labor room is performing a
fetus is determined to be 37 weeks. Which
vaginal assessment on a pregnant client
prescription should the nurse question?
in labor. The nurse notes the presence of
1. Monitor fetal heart rate continuously.
the umbilical cord protruding from the
2. Monitor maternal vital signs frequently.
vagina. What is the first nursing action
3. Perform a vaginal examination every
with this finding?
shift.
1. Gently push the cord into the vagina.
4. Administer ampicillin 1 g as an
2. Place the client in Trendelenburg's
intravenous piggyback every 6 hours.
position.
3. Find the closest telephone and page
3. Perform a vaginal examination every shift.
the health care provider stat.
4. Call the delivery room to notify the staff
24. The nurse has developed a plan of care
that the client will be transported
for a client experiencing dystocia and
immediately.
includes several nursing actions in the
plan of care. What is the priority nursing
2. Place the client in Trendelenburg's position.
action?
1. Providing comfort measures
28. A nurse is providing emergency measures
2. Monitoring the fetal heart rate
to a client in labor who has been
3. Changing the client's position frequently
diagnosed with a prolapsed cord. The
4. Keeping the significant other informed
mother becomes anxious and frightened
of the progress of the labor
and says to the nurse, "Why are all of
these people in here? Is my baby going to
2. Monitoring the fetal heart rate
be all right?" Which client problem is most
appropriate to address at this time?
25. Fetal distress is occurring with a laboring
1. The client's fear
client. As the nurse prepares the client for
2. The client's fatigue
a cesarean birth, what is the most
3. The client's inability to control the
important nursing action?
situation
1. Slow the intravenous flow rate.
4. The client's inability to cope with the
2. Place the client in a high Fowler's
situation
position.
3. Continue the oxytocin (Pitocin) drip if
1. The client's fear
infusing.
4. Administer oxygen, 8 to 10 L/minute,
via face mask.
29. The maternity nurse is caring for a client
with abruptio placentae and is monitoring
her for disseminated intravascular
coagulation. Which assessment findings
are most likely associated with
disseminated intravascular
coagulation? Select all that apply.
1. Hematuria
2. Prolonged clotting times
3. Increased platelet count
4. Swelling of the calf of one leg
5. Petechiae, oozing from injection sites,
and hematuria
o 1. Hematuria
o 2. Prolonged clotting times
o 5. Petechiae, oozing from injection
sites, and hematuria
30. The nurse in a labor room is assisting with
the vaginal delivery of a newborn infant.
The nurse should monitor the client
closely for the risk of uterine rupture if
which occurred?
1. Forceps delivery
2. Schultz presentation
3. Hypotonic contractions
4. Weak bearing-down efforts
1. Forceps delivery
31. The nurse is caring for a client who is
experiencing a precipitous labor and is
waiting for the health care provider to
arrive. When the infant's head crowns,
what instruction should the nurse give the
client?
1. Bear down.
2. Hold her breath.
3. Breathe rapidly.
4. Push with each contraction.
3. Breathe rapidly.
32. The nurse explains the purpose of
effleurage to a client in early labor. Which
statement should the nurse include in the
explanation?
1. "It is the application of pressure to the
sacrum to relieve a backache."
2. "It is a form of biofeedback to enhance
bearing-down efforts during delivery."
3. "It is light stroking of the abdomen to
facilitate relaxation during labor and
provide tactile stimulation to the fetus."
4. "It is performed to stimulate uterine
activity by contracting a specific muscle
group while other parts of the body rest."
3. "It is light stroking of the abdomen to
facilitate relaxation during labor and provide
tactile stimulation to the fetus."
33. A client in labor is dilated 10 cm. At this
point in the labor process, at least how
often should the nurse plan to assess and
document the fetal heart rate?
1. Hourly
2. Every 15 minutes
3. Every 30 minutes
4. Before each contraction
2. Every 15 minutes
34. The nurse is caring for a client in labor
and prepares to auscultate the fetal heart
rate by using a Doppler ultrasound device.
Which action should the nurse take to
determine fetal heart sounds accurately?
1. Noting whether the heart rate is greater
than 140 beats/min
2. Placing the diaphragm of the Doppler
on the mother's abdomen
3. Palpating the maternal radial pulse
while listening to the fetal heart rate
4. Performing Leopold's maneuver first to
determine the location of the fetal heart
3. Palpating the maternal radial pulse while
listening to the fetal heart rate
35. The nurse is caring for a client in labor
who is receiving oxytocin (Pitocin) by
intravenous infusion to stimulate uterine
contractions. Which assessment finding
should indicate to the nurse that the
infusion needs to be discontinued?
1. Increased urinary output
2. A fetal heart rate of 90 beats/min
3. Three contractions occurring within a
10-minute period
4. Adequate resting tone of the uterus
palpated between contractions
2. A fetal heart rate of 90 beats/min
36. The nurse is preparing to care for a client
in labor. The health care provider has
prescribed an intravenous (IV) infusion of
oxytocin (Pitocin). The nurse ensures that
 which intervention is implemented before
initiating the infusion?
1. An IV infusion of antibiotics
2. Placing the client on complete bed rest
3. Continuous electronic fetal monitoring
4. Placing a code cart at the client's
bedside
3. Continuous electronic fetal monitoring
37. The nurse assists in the vaginal delivery
of a newborn infant. After the delivery, the
nurse observes the umbilical cord
lengthen and a spurt of blood from the
vagina. The nurse documents these
observations as signs of which condition?
1. Hematoma
2. Uterine atony
3. Placenta previa
4. Placental separation
4. Placental separation
38. During the intrapartum period, a nurse is
caring for a client with sickle cell disease.
The nurse ensures that the client receives
adequate intravenous fluid intake and
oxygen consumption to achieve which
outcome?
1. Stimulate the labor process.
2. Prevent dehydration and hypoxemia.
3. Avoid the necessity of a cesarean
delivery.
4. Eliminate the need for analgesic
administration.
2. Prevent dehydration and hypoxemia.
39. A client with a 38-week twin gestation is
admitted to a birthing center in early labor.
One of the fetuses is a breech
presentation. Which intervention is least
appropriate in planning the nursing care
of this client?
1. Measure fundal height.
2. Attach electronic fetal monitoring.
3. Prepare the client for a possible
cesarean section.
4. Visually examine the perineum and
vaginal opening.
1. Measure fundal height.
40. The nurse prepares a plan of care for the
client with preeclampsia and documents
that if the client progresses from
preeclampsia to eclampsia, the nurse
should take which first action?
1. Administer oxygen by face mask.
2. Clear and maintain an open airway.
3. Administer magnesium sulfate
intravenously.
4. Assess the blood pressure and fetal
heart rate.
2. Clear and maintain an open airway.
41. A prenatal client with vaginal bleeding is
being admitted to the labor unit. The labor
room nurse is performing the admission
assessment and would suspect a
diagnosis of placenta previa if which
finding is noted?
1. Back pain
2. Abdominal pain
3. Painful vaginal bleeding
4. Painless vaginal bleeding
4. Painless vaginal bleeding
42. A prenatal client with severe abdominal
pain is admitted to the maternity unit. The
nurse is monitoring the client closely
because concealed bleeding is suspected.
Which assessment finding would indicate
the presence of concealed bleeding?
1. Back pain
2. Heavy vaginal bleeding
3. Increase in fundal height
4. Early deceleration on the fetal heart
monitor
3. Increase in fundal height
43. The nurse is caring for a client during the
second stage of labor. On assessment,
the nurse notes a slowing of the fetal
heart rate and a loss of variability. Which
is the initial nursing action?
1. Turn the client onto her side and give
oxygen by face mask at 8 to 10 L/min.
2. Turn the client onto her back and give
oxygen by face mask at 8 to 10 L/min.
3. Turn the client onto her side and give
oxygen by nasal cannula at 2 to 4 L/min.
4. Turn the client onto her back and give
oxygen by nasal cannula at 2 to 4 L/min.
 1. Turn the client onto her side and give
oxygen by face mask at 8 to 10 L/min.
44. An amniotomy is performed on a client in
labor. On the amniotic fluid examination,
the delivery room nurse would identify
which findings as normal?
1. Light green, with no odor
2. Clear and dark amber-colored
3. Thick and white, with no odor
4. Pale straw-colored, with flecks of vernix
4. Pale straw-colored, with flecks of vernix
45. A labor room nurse is performing an
assessment on a client in labor and notes
that the fetal heart rate (FHR) is 158
beats/min and regular. The client's
contractions are every 5 minutes, with a
duration of 40 seconds and of moderate
intensity. On the basis of these
assessment findings, what is the
appropriate nursing action?
1. Contact the obstetrician.
2. Continue to monitor the client.
3. Report the FHR to the anesthesiologist.
4. Prepare for imminent delivery of the
fetus.
2. Continue to monitor the client.
46. The nurse is developing a plan of care for
a pregnant client with a diagnosis of
severe preeclampsia. Which nursing
actions should be included in the care
plan for this client? Select all that apply.
1. Keep the room semi-dark.
2. Initiate seizure precautions.
3. Pad the side rails of the bed.
4. Avoid environmental stimulation.
5. Allow out-of-bed activity as tolerated.
o 1. Keep the room semi-dark.
o 2. Initiate seizure precautions.
o 3. Pad the side rails of the bed.
o 4. Avoid environmental stimulation.
47. The labor room nurse assists with the
administration of a lumbar epidural block.
How should the nurse check for the major
side effect associated with this type of
regional anesthesia?
1. Assessing the mother's reflexes
2. Taking the mother's temperature
3. Taking the mother's apical pulse
4. Monitoring the mother's blood pressure
4. Monitoring the mother's blood pressure
48. A nurse assists the health care provider to
perform an amniotomy on a client in labor.
Which is the priority nursing action after
this procedure?
1. Assess the fetal heart rate.
2. Check the client's temperature.
3. Change the pads under the client.
4. Check the client's respiratory rate.
1. Assess the fetal heart rate.
49. The goal for a woman with partial
premature separation of the placenta is,
"The woman will not exhibit signs of fetal
distress." Which outcome, documented by
the nurse, would indicate that this goal
has been achieved?
1. No accelerations of FHR
2. Short-term variability present
3. Variable decelerations present
4. Fetal heart rate (FHR) of 170 to 180
beats/min
2. Short-term variability present
50. The nurse is assessing the deep tendon
reflexes of a client with severe
preeclampsia who is receiving intravenous
magnesium sulfate. The nurse should
perform which procedure to assess the
brachioradialis reflex?
1. A
2. B
3. C
4. D
1. A
51. The nurse is caring for a client in active
labor. Which nursing intervention would
 be the best method to prevent fetal heart
rate decelerations?
1. Prepare the client for a cesarean
delivery.
2. Monitor the fetal heart rate every 30
minutes.
3. Encourage an upright or side-lying
maternal position.
4. Increase the rate of the oxytocin
(Pitocin) infusion every 10 minutes.
3. Encourage an upright or side-lying maternal
position.
52. The nurse is administering magnesium
sulfate to a client for preeclampsia at 34
weeks gestation. What is
the priority nursing action for this client?
1. Assess for signs and symptoms of
labor.
2. Assess the client's temperature every 2
hours.
3. Schedule a daily ultrasound to assess
fetal movement.
4. Schedule a non-stress test every 4
hours to assess fetal well-being.
1. Assess for signs and symptoms of labor.
53. The nurse is preparing to administer an
analgesic to a client in labor. Which
analgesic is contraindicated for a client
who has a history of opioid dependency?
1. Fentanyl
2. Morphine sulfate
3. Butorphanol tartrate
4. Meperidine hydrochloride (Demerol)
3. Butorphanol tartrate
54. The nurse in a delivery room is assessing
a client immediately after delivery of the
placenta. Which maternal observation
could indicate uterine inversion and
require immediate intervention?
1. Chest pain
2. A rigid abdomen
3. A soft and boggy uterus
4. Complaints of severe abdominal pain
4. Complaints of severe abdominal pain
55. The nurse is caring for a client in the
transition phase of the first stage of labor.
The client is experiencing uterine
contractions every 2 minutes and she
cries out in pain with each contraction.
What is the nurse's best interpretation of
this client's behavior?
1. Exhaustion
2. Valsalva maneuver
3. Involuntary grunting
4. Fear of losing control
4. Fear of losing control
56. A pregnant client is admitted in labor. The
nursing assessment reveals that the
client's hemoglobin and hematocrit levels
are low, indicating anemia. What should
the nurse observe for throughout the
client's labor?
1. Anxiety
2. Hemorrhage
3. Low self-esteem
4. Postpartum infection
4. Postpartum infection
57. Fetal distress is occurring with a woman in
labor. As the nurse prepares her for a
cesarean birth, what other intervention
should the nurse implement?
1. Slow the intravenous (IV) rate.
2. Continue the oxytocin (Pitocin) drip.
3. Place the client in a high Fowler's
position.
4. Administer oxygen at 8 to 10 L/min via
face mask.
4. Administer oxygen at 8 to 10 L/min via face
mask.
58. A pregnant 39-week-gestation gravida 1
para 0 client arrives on the labor and
delivery unit with signs and symptoms of
active labor. The nurse reviews the
client's prenatal record and discovers that
she has had a positive group
B Streptococcus(GBS) laboratory report
during her prenatal course. After
performing a cervical exam, the nurse
confirms that the cervix is dilated 6 cm
and 90% effaced. Which should be the
nurse's first action?
1. Provide the client with instructions on
how to push.
2. Prepare the labor room and the client
 for an imminent delivery.
3. Call the HCP to obtain a prescription for
intravenous antibiotic prophylaxis (IAP).
4. Call the health care provider (HCP) to
the labor and delivery unit to perform a
delivery.
3. Call the HCP to obtain a prescription for
intravenous antibiotic prophylaxis (IAP).
59. A pregnant 39-week-gestation client
arrives at the labor and delivery unit in
active labor. On confirmation of labor, the
client reports a history of herpes simplex
virus (HSV) to the nurse, who notes the
presence of lesions on inspection of the
client's perineum. Which should be the
nurse's initial action?
1. Perform an abdominal prep on the
client.
2. Prepare the delivery room for a vaginal
delivery.
3. Explain to the client why a cesarean
delivery is necessary.
4. Call the health care provider to obtain a
prescription for an antiviral medication.
3. Explain to the client why a cesarean
delivery is necessary.
60. The nurse caring for a client in labor notes
that minimal variability is present on a
fetal heart rate (FHR) monitor strip. Which
best describes minimal variability?
1. FHR fluctuations are lasting more than
15 seconds.
2. FHR fluctuations last at least 15
seconds and go at least 15 beats/min
below the baseline rate.
3. FHR fluctuations are lasting more than
15 seconds.
4. FHR fluctuations last at least 15
seconds and go at least 15 beats/min
below the baseline rate.
1. FHR fluctuations are lasting more than 15
seconds.
61. After the spontaneous rupture of a
laboring woman's membranes, the fetal
heart rate drops to 85 beats/minute.
Which should be the
nurse's priority action?
1. Reposition the laboring woman to knee-
chest.
2. Assess the vagina and cervix with a
gloved hand.
3. Notify the health care provider of the
need for an amnioinfusion.
4. Document the description of the fetal
bradycardia in the nursing notes.
2. Assess the vagina and cervix with a gloved
hand.
62. On assessment of the fetal heart rate
(FHR) of a laboring woman, the nurse
discovers decelerations that have a
gradual onset, last longer than 30
seconds, and return to the baseline rate
with the completion of each contraction.
The nurse plans care, knowing that this
identifies is which category of
decelerations?
1. Episodic, late decelerations that
indicate uteroplacental insufficiency
2. Periodic, early decelerations and
indicative of fetal head compression
3. Periodic, variable decelerations and an
indication of cord compression
4. Episodic, early decelerations that may
be a result of maternal hypotension
2. Periodic, early decelerations and indicative
of fetal head compression
63. Shortly after receiving epidural
anesthesia, a laboring woman's blood
pressure drops to 95/43 mm Hg.
Which immediate actions should the
nurse take? Select all that apply.
1. Prepare for delivery.
2. Administer a tocolytic.
3. Administer an opioid antagonist.
4. Turn the woman to a lateral position.
5. Increase the rate of the intravenous
infusion.
6. Administer oxygen by face mask at 10
L/minute.
o 4. Turn the woman to a lateral
position.
o 5. Increase the rate of the intravenous
infusion.
o 6. Administer oxygen by face mask at
10 L/minute.
64. The nurse is administering an intravenous
analgesic to a laboring woman. The
woman inquires as to why the nurse is
waiting for a contraction to begin before
 she infuses the medication into the
intravenous line. Which is the
nurse's most appropriate response?
1. "The medication will only affect you and
your pain level when given during a
contraction."
2. "The medication will provide the most
optimal relief when it is given while your
pain level is highest."
3. "Because the uterine blood vessels
constrict during a contraction, the fetus
will be less affected by the medication."
4. "You will experience a lower incidence
of adverse effects from the medication
when administered during a contraction."
3. "Because the uterine blood vessels
constrict during a contraction, the fetus will be
less affected by the medication."
65. On March 10, 2015, the nurse performed
an initial assessment on a client admitted
to the labor and delivery unit for "rule out
labor." The client has not received
prenatal care but is certain that the first
day of her last menstrual period (LMP)
was July 7, 2014. The nurse plans care
based on which interpretation?
1. The client is possibly in preterm labor.
2. The fetus may not be viable at delivery.
3. The client may require labor
augmentation.
4. The fetus is at high risk for shoulder
dystocia.
1. The client is possibly in preterm labor.
66. The nurse is assigned to care for a client
with hypotonic uterine dysfunction and
signs of a slowing labor. The nurse is
reviewing the health care provider's
prescriptions and would expect to note
which prescribed treatment for this
condition?
1. Increased hydration
2. Oxytocin (Pitocin) infusion
3. Administration of a tocolytic medication
4. Administration of a medication that will
provide sedation
2. Oxytocin (Pitocin) infusion
67. Which newborn is most at risk for a
brachial plexus injury?
1. A term infant with a history of a forceps-
assisted delivery
2. A term infant delivered via primary
cesarean section for malpresentation
3. A large for gestational age infant with a
history of shoulder dystocia at delivery
4. A 36-week preterm infant delivered
vaginally after preterm rupture of
membranes
3. A large for gestational age infant with a
history of shoulder dystocia at delivery
68. A woman in active labor has requested a
regional anesthetic. She is currently 5 cm
dilated. The health care provider (HCP)
has prescribed an epidural block. Which
nursing intervention would be
implemented after the epidural block has
been placed?
1. Palpate the bladder at frequent
intervals.
2. Encourage the woman to walk to
progress the labor.
3. Assess the blood pressure frequently
for hypertension.
4. Encourage the woman to assume a
supine position after the epidural has
been placed.
1. Palpate the bladder at frequent intervals.
69. A nurse is performing a vaginal
assessment of a pregnant woman who is
in labor. The nurse notes that the
umbilical cord is protruding from the
vagina. The nurse
would immediately take which action?
1. Administer oxygen to the woman.
2. Transport the woman to the delivery
room.
3. Place an external fetal monitor on the
woman.
4. Exert upward pressure against the
presenting part using a gloved hand.
4. Exert upward pressure against the
presenting part using a gloved hand.
70. A nurse in the labor room is caring for a
client who is in the first stage of labor. On
assessing the fetal patterns, the nurse
notes an early deceleration of the fetal
heart rate (FHR) on the monitor strip.
 Based on this finding, which is the
appropriate nursing action?
1. Contact the health care provider.
2. Place the mother in a Trendelenburg
position.
3. Administer oxygen to the client by face
mask.
4. Document the findings and continue to
monitor fetal patterns.
4. Document the findings and continue to
monitor fetal patterns.
71. The nurse is caring for a client who is
receiving oxytocin (Pitocin) for induction of
labor and notes a nonreassuring fetal
heart rate (FHR) pattern on the fetal
monitor. On the basis of this finding, the
nurse should take which action first?
1. Stop the oxytocin infusion.
2. Check the client's blood pressure.
3. Check the client for bladder distention.
4. Place the client in a side-lying position.
1. Stop the oxytocin infusion.
72. A nurse is caring for a client in labor. The
nurse determines that the client is
beginning the second stage of labor when
which is documented in the client's
record?
1. The contractions are regular.
2. The membranes have ruptured.
3. The cervix is completely dilated.
4. The client begins to expel clear vaginal
fluid.
3. The cervix is completely dilated.
73. A nurse is caring for a client in the active
stage of labor. The nurse notes that the
fetal pattern shows a late deceleration on
the monitor strip. Based on this finding the
nurse should prepare for which
appropriate nursing action?
1. Administering oxygen via face mask
2. Placing the mother in a supine position
3. Increasing the rate of the intravenous
(IV) oxytocin (Pitocin) infusion
4. Documenting the findings and
continuing to monitor the fetal patterns
1. Administering oxygen via face mask
74. A client in labor is receiving oxytocin
(Pitocin) by intravenous infusion to
stimulate uterine contractions. Which
finding indicates that the rate of the
infusion needs to be decreased?
1. Increased urinary output
2. A fetal heart rate of 180 beats/min
3. Three contractions occurring in a 10-
minute period
4. Adequate resting tone of the uterus
palpated between contractions
2. A fetal heart rate of 180 beats/min
75. A nurse is monitoring a client in labor
whose membranes ruptured
spontaneously. What is the initial nursing
action?
1. Determine the fetal heart rate.
2. Provide peripads for the client.
3. Take the client's blood pressure.
4. Note the amount, color, and odor of the
amniotic fluid.
1. Determine the fetal heart rate.
76. A nurse assists in the vaginal delivery of a
newborn. Following the delivery, the nurse
observes the umbilical cord lengthen and
a spurt of blood from the vagina. The
nurse should document these
observations as signs of which condition?
1. Hematoma
2. Uterine atony
3. Placenta previa
4. Placental separation
4. Placental separation
77. A nurse is preparing to care for a client in
labor. The health care provider has
prescribed an intravenous (IV) infusion of
oxytocin (Pitocin). The nurse should
ensure that which is implemented before
the beginning of the infusion?
1. An IV infusion of antibiotics
2. Placing the client on complete bed rest
3. Continuous electronic fetal monitoring
4. Placing a code cart at the client's
bedside
3. Continuous electronic fetal monitoring
78. A nurse is assisting in the care of a client
in labor who is having an amniotomy
performed. The nurse should assess that
the amniotic fluid is normal if it has which
characteristics?
1. Clear and dark amber color
2. Light green color with no odor
3. Thick white color with no odor
4. Straw-colored, with flecks of vernix
4. Straw-colored, with flecks of vernix
79. A nurse is developing a plan of care for a
client experiencing dystocia, and includes
several nursing interventions in the plan.
The nurse prioritizes the plan and selects
which nursing intervention as the highest
priority?
1. Monitoring fetal status
2. Providing comfort measures
3. Changing the client's position frequently
4. Keeping the significant other informed
of the progress of the labor
1. Monitoring fetal status
80. A nurse is monitoring a client with
dysfunctional labor for signs of fetal or
maternal compromise. Which finding
should alert the nurse to a compromise?
1. Maternal fatigue
2. The passage of meconium
3. Coordinated uterine contractions
4. Progressive changes in the cervix
2. The passage of meconium
81. A nurse is preparing to care for a client
with hypertonic labor. The nurse is told
that the client is experiencing
uncoordinated contractions that are erratic
in their frequency, duration, and intensity.
Which is the priority nursing intervention?
1. Provide pain relief measures.
2. Prepare the client for an amniotomy.
3. Promote ambulation every 30 minutes.
4. Monitor the oxytocin (Pitocin) infusion
closely.
1. Provide pain relief measures.
82. A nurse performs a vaginal assessment
on a pregnant client in labor. On
assessment, the nurse notes the
presence of the umbilical cord protruding
from the vagina. Which is
the initial nursing action?
1. Gently push the cord into the vagina.
2. Place the client in Trendelenburg's
position.
3. Find the closest telephone and page
the health care provider stat.
4. Call the delivery room to notify the staff
that the client will be transported
immediately.
2. Place the client in Trendelenburg's position.
83. A nurse is caring for a client during the
second stage of labor. On assessment,
the nurse notes a slowing of the fetal
heart rate and a loss of variability. What is
the initial nursing action?
1. Turn the client on her side and
administer oxygen by face mask at 8 to 10
L/min.
2. Turn the client on her back and
administer oxygen by face mask at 8 to 10
L/min.
3. Turn the client on her side and
administer oxygen by nasal cannula at 2
to 4 L/min.
4. Turn the client on her back and
administer oxygen by nasal cannula at 2
to 4 L/min.
1. Turn the client on her side and administer
oxygen by face mask at 8 to 10 L/min.
84. An ultrasound is performed on a client
with suspected abruptio placentae, and
the results indicate that a placental
abruption is present. Which intervention
should the nurse prepare the client for?
1. Delivery of the fetus
2. Strict monitoring of intake and output
3. Complete bed rest for the remainder of
the pregnancy
4. The need for weekly monitoring of
coagulation studies until the time of
delivery
1. Delivery of the fetus
85. A nurse is monitoring a client who is in the
active phase of labor. The client has been
experiencing contractions that are short,
irregular, and weak. Which type of labor
 dystocia should the nurse document that
the client is experiencing?
1. Hypotonic
2. Precipitate
3. Hypertonic
4. Preterm labor
1. Hypotonic
86. A nurse has collected the following data
on a client in labor. The fetal heart rate
(FHR) is 154 beats/min and is regular;
and contractions have moderate intensity,
occur every 5 minutes and have a
duration of 35 seconds. Using this
information, what is
the most appropriate action for the nurse
to take?
1. Prepare for imminent delivery.
2. Continue to monitor the client.
3. Report the findings to the obstetrician.
4. Report the FHR to the anesthesiologist
on call.
o 3. Effacement
89. A nurse is collecting data from a pregnant
client in the second trimester of pregnancy
who was admitted to the maternity unit
with a suspected diagnosis of abruptio
placentae. Which findings are associated
with abruptio placentae? Select all that
apply.
1. Uterine tenderness
2. Acute abdominal pain
3. A hard, "board-like" abdomen
4. Painless, bright red vaginal bleeding
5. Increased uterine resting tone on fetal
monitoring
o 1. Uterine tenderness
o 2. Acute abdominal pain
o 3. A hard, "board-like" abdomen
o 5. Increased uterine resting tone on
fetal monitoring

2. Continue to monitor the client.

87. A pregnant client admitted to the labor

room arrived with a fetal heart rate (FHR)
of 94 beats/min and the umbilical cord
protruding from the vagina. The client tells
the nurse that her "water broke" before
coming to the hospital. What is the most
appropriate nursing action?
1. Sit the client in a high Fowler's position.
2. Call the pharmacy for a tocolytic
medication.
3. Get intravenous (IV) therapy equipment
and solution from the storage area.
4. Wrap the cord loosely in a sterile towel
soaked with warm, sterile normal saline.

4. Wrap the cord loosely in a sterile towel

soaked with warm, sterile normal saline.

88. The purpose of a vaginal examination is to

specifically assess the status of which
findings? Select all that apply.
1. Station
2. Dilation
3. Effacement
4. Bloody show
5. Contraction effort
o 1. Station
o 2. Dilation