Chapter 16 - NCLEX® Review Questions Processes and Stages of Labor and Birth

1.

A nurse is reviewing the factors important in the process of labor. Which two pelvic types are favorable for labor and vaginal delivery?

a. Gynecoid and android

b. Platypelloid and anthropoid

c. Gynecoid and anthropoid

d. Android and platypelloid

Answer: c. Gynecoid and anthropoid

Feedback: Gynecoid and anthropoid pelvis types are favorable for labor or delivery, whereas android and platypelloid pelvis types are not favorable.

Analysis; Health Promotion and Maintenance; Comprehension

2.

A client at 39 weeks' gestation calls the clinic nurse to report increasing pelvic pressure, increased energy, and vaginal secretions. The nurse would correctly interpret these as signs and symptoms of:

a. A vaginal infection.

b. Impending labor.

c. A urinary tract infection.

d. Rupture of membranes.

Answer: b. Impending labor.

Feedback: Pelvic pressure, diarrhea, and vaginal secretions are symptoms of impending labor. Vaginal infection may be recognized by an odor to the vaginal secretions, along with back or abdominal pain and fever. Urinary tract infection will present with a strong odor to the urine, along with pain and/or burning upon urination with possible fever. Although rupture of membranes precedes labor in 12% of cases, it likely would be accompanied by the expulsion of large amounts of amniotic fluid.

Analysis; Health Promotion and Maintenance; Analysis

3.

A nurse is caring for a client admitted to the birthing unit with rupture of membranes for 2 hours. A pelvic exam reveals a dilatation of 4 cm, and the presenting part is not engaged. Which possible complication should the nurse anticipate?

a. Prolapsed cord

b. Placenta previa

c. Amniotic infection

d. Abruptio placentae

Answer: a. Prolapsed cord

Feedback: When a pelvic exam reveals a dilatation of 4 cm and the presenting part is not engaged, the nurse should anticipate a prolapsed cord. With placenta previa, the placenta is implanted in the lower uterine segment rather than the upper portion of the uterus, and it is not a complication of ruptured membranes or cervical dilatation. Amniotic infection is a potential complication after the membranes have been ruptured for more than 12 hours, especially if uterine contractions are present. Abruptio placentae is the premature separation of a normally implanted placenta from the uterine wall, and is not a complication of ruptured or cervical dilatation.

Analysis; Health Promotion and Maintenance; Analysis

4.

A G4P3 client who has just entered the second stage of labor asks the nurse, "How much longer will it be before I have my baby?" What would be the best estimate that the nurse could provide?

a. One hour

b. Two hours

c. Three hours

d. Four hours

Answer: a. One hour

Feedback: One hour is a reasonable estimate of time until delivery for a multipara woman in transition. Three hours or less would be a more appropriate answer for a nullipara woman.

5.

A laboring client complains of nausea, vomiting, and increasing rectal pressure. She states, "I can't take this anymore." The nurse correctly assesses that this client is in which phase of labor?

a. Latent

b. Active

c. Transition

d. Second stage

Answer: c. Transition

Feedback: Transition is the phase of labor where clients usually complain of nausea, vomiting, and increasing rectal pressure, and state, "I can't take any more." A laboring client usually is able to cope in the latent and active phases of labor. Nausea, vomiting, and rectal pressure decrease during the second stage with the birth of the baby.

Analysis; Health Promotion and Maintenance; Analysis

6.

A nurse assesses a rise in the fundal height and a sudden gush of blood from the vagina of a postpartum client 5 minutes after birth. The nurse appropriately interprets these finding as:

a. Immediate postpartum hemorrhage.

b. Separation of the placenta.

c. Late postpartum hemorrhage.

d. Delivery of the placenta.

Answer: b. Separation of the placenta.

Feedback: Separation of the placenta is characterized by a rise in fundal height and sudden gush of blood 5 minutes after birth. Immediate postpartum hemorrhage is not characterized by a rise in fundal height. Late postpartum hemorrhage occurs 24-48 hours or more after birth. Delivery of the placenta is characterized by a decrease in fundal height.

Analysis; Health Promotion and Maintenance; Analysis

7.

A nurse is caring for a client during the fourth stage of labor. What are the expected assessment findings at this time?

a. Decreased blood pressure and increased pulse

b. Increased blood pressure and increased pulse

c. Decreased blood pressure and decreased pulse

d. Increased blood pressure and decreased pulse

Answer: a. Decreased blood pressure and increased pulse

Feedback: Decreased blood pressure and increased pulse are the expected assessment findings during the fourth stage of labor.

Assessment; Physiological Integrity; Analysis

8.

A laboring client asks the nurse how often she is having contractions. Which method of measuring the interval between contractions will enable the nurse to give an accurate answer to client's question?

a. Determine the interval between the acme of one contraction and the acme of the next.

b. Determine the interval between the end of one contraction and the beginning of the next.

c. Determine the interval between the contractions that are strong to palpation.

d. Determine the interval between the beginning of one contraction and the beginning of the next.

Answer: d. Determine the interval between the beginning of one contraction and the beginning of the next.

Feedback: Measuring the time from the beginning of one contraction to the beginning of the next contraction is the standard method for describing and documenting the frequency of contractions.

Implementation; Safe, Effective Care Environment; Application

9.

A pregnant client asks the nurse, "How will I know when I am close to starting labor?" The nurse correctly states that one possible sign of impending labor is:

a. Loss of weight.

b. Increase in appetite.

c. Feeling of fatigue.

d. Abdominal discomfort.

Answer: a. Loss of weight.

Feedback: Impending labor may be indicated by a weight loss of 2.2-6.6 kg (1-3 lb) resulting from fluid loss and electrolyte shifts produced by changes in estrogen and progesterone levels. Diarrhea, indigestion, or nausea and vomiting usually occur just prior to the onset of labor. Some women report a sudden burst of energy approximately 24-48 hours before labor. Abdominal discomfort can be a sign of false labor.

Implementation; Health Promotion and Maintenance; Knowledge

10.

A laboring client complains to the nurse about intense pain located primarily in her back. Which fetal position should the nurse expect to see written on the client's chart?

a. Right-occiput-anterior (ROA)

b. Left-mentum-transverse (LMT)

c. Right-sacrum-anterior (RSA)

d. Left-occiput-posterior (LOP)

Answer: d. Left-occiput-posterior (LOP)

Feedback: Either occiput-posterior (LOP or ROP) position of the fetus would cause a woman to complain of intense backache, as the fetal head presents a larger diameter in the posterior position. The anterior positions and transverse positions do not place additional pressure on the sacrum and are not associated with intense backache.

Analysis; Health Promotion and Maintenance; Analysis

11.

A G4P3 at term presents to the labor and birth unit apparently in active labor. Her birth plan states she is an Orthodox Jew and that she would like to observe her religious traditions around childbirth. Her husband hugs her, states he will be in the waiting room, and leaves the client alone with the nurse. What is the most appropriate nursing response?

Assess the client for signs of domestic abuse.

Reassure the client that the nursing staff will be present and supportive.

Encourage the husband to participate in the labor and birth process.

Tell the client that most fathers are present for the birth of their children.

Answer: b. Reassure the client that the nursing staff will be present and supportive.

Feedback: Some cultures, including Orthodox Judaism, do not value and may even prohibit the participation of men in labor and birth. Screening for domestic abuse should be done for all clients but following traditional cultural practices is not evidence of increased risk. Encouraging the family to act against their preferences and discussing the preferences of other families is not therapeutic or appropriate.

12.

When the presenting part is the fetal head, which cardinal movement occurs when resistance from the pelvic structures during contractions causes the fetal chin to be tucked onto the chest and the spine to curve ventrally?

Descent

Flexion

Internal rotation

Restitution

Answer: b. Flexion

Feedback: Flexion occurs when resistance from the structures of the pelvis and genital tract flexes the fetal neck so that the chin touches the chest, the spine curves ventrally, and the vertex presents. Descent is the progressive movement of the fetus toward the vaginal introitus. Internal rotation is the alignment of the fetal head with the anteroposterior diameters of each plane of the pelvis as it descends. Restitution is the realignment of the fetal head with the shoulders after the head is born.