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Answer: A
2. A postpartum patient was in labor for 30 hours and had ruptured membranes
for 24 hours. For which of the following would the nurse be alert?
A. Endometritis
B. Endometriosis
C. Salpingitis
D. Pelvic thrombophlebitis
Answer: A
3. A nurse is caring for a client in labor. The nurse determines that the client is
beginning in the second stage of labor when which of the following assessments is
noted?
Answer: D
4. A nurse is performing an assessment of a client who is scheduled for a cesarean
delivery. Which assessment finding would indicate a need to contact the physician?
Answer: A
5. A 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 BPM. Which of the following nursing actions
is most appropriate?
Answer: D
A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between
contractions may indicate the need for immediate medical management, and the
physician or nurse-midwife needs to be notified.
6. A nurse in the delivery room is assisting with the delivery of a newborn infant.
After the delivery of the newborn, the nurse assists in delivering the placenta.
Which observation would indicate that the placenta has separated from the uterine
wall and is ready for delivery?
Answer: D
Answer: A
Presentation is the fetal body part that enters the pelvis first; it’s classified by the
presenting part; the three main presentations are cephalic/occipital, breech, and shoulder.
Option B: The relationship of the presenting fetal part to the maternal pelvis
refers to fetal position.
Option C: The relationship of the long axis to the fetus to the long axis of the
mother refers to fetal lie; the three possible lies are longitudinal, transverse, and
oblique.
8. A multiparous client who has been in labor for 2 hours states that she feels the
urge to move her bowels. How should the nurse respond?
Answer: C
A complaint of rectal pressure usually indicates a low presenting fetal part, signaling
imminent delivery. The nurse should perform a pelvic examination to assess the dilation
of the cervix and station of the presenting fetal part.
Answer: A
When cord prolapse occurs, prompt actions are taken to relieve cord compression and
increase fetal oxygenation. The mother should be positioned with the hips higher than the
head to shift the fetal presenting part toward the diaphragm. Oxygen at 8 to 10 L/min by
face mask is delivered to the mother to increase fetal oxygenation.
Options B and D: The nurse should push the call light to summon help, and
other staff members should call the physician and notify the delivery room.
Option C: No attempt should be made to replace the cord. The examiner,
however, may place a gloved hand into the vagina and hold the presenting part
off of the umbilical cord.
10. The breathing technique that the mother should be instructed to use as the fetus’
head is crowning is:
A. Blowing
B. Slow chest
C. Shallow
D. Accelerated-decelerated
Answer: A
Blowing forcefully through the mouth controls the strong urge to push and allows for a
more controlled birth of the head.