MCN Exam 2: Intrapartum NCLEX-Style Questions

MCN Exam 2: Intrapartum NCLEX-Style Questions

Leave the first rating Students also studied Terms in this set (47) Science MedicineObstetrics Save Antepartum NCLEX questions 50 terms smbauer2Preview Intrapartum NCLEX style questions 55 terms mimimoneyPreview OB Postpartum NCLEX Questions 52 terms ashley_coots7 Preview Intrapa 14 terms ans A woman is 40 weeks pregnant & reports feeling a sudden gush of fluid and suspects her water may have broken. What should the RN advise the woman to do?

• Wait at home and monitor for contractions.
• Drink plenty of fluids to stay hydrated.
• Lie down and rest for at least 2 hours.
• Seek immediate medical attention for assessment.

Answer: D

Rationale: Spontaneous rupture of membranes (SROM), or the "water breaking," can lead to complications, such as infection, if not properly managed so she should seek immediate medical attention for an assessment to confirm if her water broke.

SATA: Which of the following a premonitory signs of

labor?

• "Bloody show"
• Lightening
• Braxton Hicks contractions
• Cervical changes
• Nesting

Answer: All of the above

Rationale: N/A

A nursing student is reviewing the signs of true labor.Which statement by the student correctly identifies a sign of true labor?

• "Contractions that are relieved by changing positions."
• "Pain starting in the abdomen and radiating to the

back."

• "Irregular contractions occurring every 10-15 minutes."
• "Pain felt in front of the abdomen."

Answer: B

Rationale: True labor involves strong, regular, & frequent contractions unrelieved by position changes, walking, or hydration. Pain felt during true labor will start in the abdomen and radiate to the lower back.

A 28-year-old female gives birth to twins at 38 weeks gestation. This is her first pregnancy. Which option below best describes the patient's gravidity and parity?

• Gravida 1, para 1
• Gravida 1, para 2
• Gravida 2, para 2
• Gravida 1, para 0

Answer: A

Rationale: Gravida is the number of times a woman has been pregnant regardless

of the outcome. The patient has been pregnant once (twins or multiples count as one). Parity is the number of births that occurred after 20 weeks gestation. The patient's parity is 1 (twins or multiples count as a one).

True or false: During the initial maternal assessment it is

important to ask when the membranes ruptured due to an increased risk for infection if delivery is not completed within 18 hours.

Answer: true

Rationale: N/A

A nursing student is learning about maternal assessments and the use of Leopold's maneuvers during pregnancy.Which statement by the student indicates a correct understanding of the purpose of Leopold's maneuvers?

• "It helps determine fetal heart rate and assess uterine

contractions."

• "It assists in locating the fetal heartbeat and

determining fetal position and presentation."

• "It's performed to measure fundal height and estimate

gestational age."

• "It's used to assess the dilation and effacement of the

cervix during labor."

Answer: B

Rationale: Leopold's maneuvers are a systematic, four-step process used to

determine the position and presentation of the fetus. They involve palpation and assessment of the maternal abdomen to identify the fetal parts and their relationships, aiding in the determination of fetal position and presentation.A nursing student is studying fetal stationing during labor.Which statement by the student indicates a correct understanding of fetal station?

• "It is the measurement of the fetal head in relation to

the maternal symphysis pubis and is recorded as a negative or positive value."

• "It refers to the descent of the fetal buttocks into the

pelvis, indicating engagement in the birth canal."

• "It is determined by assessing the frequency and

intensity of uterine contractions during labor."

• "It is the measurement of the diagonal diameter of the

fetal head in relation to the maternal pelvic inlet."

Answer: A

Rationale: Fetal station is the measurement of the fetal head in relation to the maternal ischial spines or symphysis pubis. It is recorded as a negative (below) or positive (above) value, indicating the level of descent of the fetal head in the birth canal.

SATA: Which of the following labs are completed during

pregnancy?

• Hepatitis B
• HIV testing
• Syphilis testing (VDRL)
• Toxicology screening
• Group B strep test

Answer: All of the above

Rationale: N/A

True or false: RhoGam is considered a blood product

therefore additional consent is required prior to administration.

Answer: true

Rationale: N/A

A woman who is 38 weeks pregnant & tested positive for Group B step is preparing for labor. Given her Group B strep status, which RN intervention is most appropriate?

• Administer IV vancomycin
• Administer IV clindamycin
• Administer PO penicillin
• Administer PO tetracycline

Answer: B

Rationale: If a patient's Group B strep status is positive OR known, they should receive IV penicillin or clindamycin every 4 hours until delivery.

True or false: Upon completion of an artificial rupture of

membranes (AROM), the HCP should monitor for signs of hydramnios.

Answer: False

Rationale: Hydramnios is excessive amniotic fluid & usually indicates the fetus is not swallowing enough. The HCP should monitor for signs of hydramnios upon spontaneous rupture of membranes (SROM) or "Water breaking."

SATA: Which of the following must be documented upon

completion of an artificial rupture of membranes

(AROM)?

• Amount of amniotic fluid
• Odor of amniotic fluid
• Time of membrane rupture
• pH of amniotic fluid
• Color of amniotic fluid

Answer: B, C, & E

Rationale: Amniotic fluid should be clear & odorless. If amniotic fluid is odorous or a different color it could indicate infection or bleeding. Time of membrane rupture is required due to increased risk for infection if delivery is not completed within 18 hours.A woman who is 39 weeks pregnant is in the hospital preparing to give birth. When assisting with position changes, the RN notices green fluid on the towel underneath the woman after she reports her water broke.Based on her assessment, the RN may assume?

• Abruptio placentae is occurring.
• The mother has a bacterial infection.
• Fetal death has occurred.
• The fetus is in distress.

Answer: D

Rationale: Amniotic fluid color is best assessed on a white towel. Green amniotic fluid indicates meconium meaning the fetus is in distress & at an increased risk for aspiration. An amnioinfusion should be performed to dissolve the meconium & replace the amniotic fluid.A woman presents with bleeding upon the rupture of her membrane (ROM). Which intervention should the RN do first?

• Perform a cervical exam
• Assist with completing an ultrasound
• Have labs done for a platelet count & H/H level
• Massage the fundus

Answer: B

Rationale: If a patient has bleeding upon ROM, an ultrasound should be

completed first to rule out abruptio placentae or placenta previa.

True or false: A cervical exam should be done if a woman

is experiencing preterm, premature rupture of membranes (PPROM).

Answer: false

Rationale: Performing a cervical exam upon PPROM may increase the risk of

infection therefor it should be limited.A woman is 33 weeks pregnant & reports blood-tinged vaginal discharge. A fetal fibronectin test is done & the results are positive. Based on the results, what is the correct diagnosis?

• Abruptio placentae
• Severe preeclampsia
• Placenta previa
• Uterine infection

Answer: A

Rationale: Fibronectin is a protein that bind the fetal sac to the uterine lining. A positive fetal fibronectin test indicates the placenta is detaching from the uterine wall & they're at risk for preterm labor.

SATA: Which of the following are risk factors for preterm

labor (PTL)?

• Uncontrolled hypertension
• An A1C of 14
• Testing positive for HIV
• Pregnant with twins
• Missing prenatal appointments

Answer: A, B, D, & E

Rationale: Risk factors for PTL include a previous history of PTL or PPROM,

diabetes, chronic HTN, & a lack of prenatal care A woman is 32 weeks pregnant & experiencing contractions despite her membrane being intact. Which of the following intervention by the RN is most appropriate?

• Administer tocolytics only
• Administer betamethasone & IV antibiotics
• Administer tocolytics, betamethasone, & IV antibiotics
• Administer tocolytics & betamethasone

Answer: D

Rationale: The woman is less than 38 weeks pregnant but experiencing

contractions meaning she's having preterm labor (PTL). Tocolytics are given to slow down contractions to delay labor & betamethasone is given to encourage fetal lung maturity to decrease the risk of respiratory distress syndrome (RDS) as the woman prepares for birth.

SATA: Which of the following medications are tocolytic

meds?

• Magnesium sulfate
• Nifedipine
• Terbutaline
• Oxytocin
• Estrogen

Answer: A, B, & C

Rationale. Tocolytic meds are used to slow or stop contractions. Magnesium sulfate (magnesium supplement), Nifedipine (calcium-channel blocker), & Terbutaline (bronchodilator) all act a smooth muscle relaxer to improve circulation leading to decreased contractions.A woman is 36 weeks pregnant & preparing for labor.Upon assessment the RN notes absent DTRs, BP of 110/70, & respirations of 10 breaths/min. Which intervention is most appropriate?

• Administer her next dose of terbutaline & notify he

HCP.

• Hold her next dose of magnesium sulfate & notify the

HCP.

• Provide supplemental O2 & assist with positive

changes.

• Apply SCDs & reassess her respirations.

D.

Answer: B

Rationale: Magnesium sulfate may be given as intervention for preterm labor. The patient is experience magnesium toxicity so the medication shouldn't be given.Signs of magnesium toxicity include decreased DTRs, respiratory depression, hypotension, muscular weakness, N/V, decreased urine output, & mental status changes.

What is the expected rate of dilation?Answer: 1-1.5 cm/hr

Rationale: N/A

Fill in the blank: Stage 1 of labor includes the _____ & _____

phases.

Answer: active & latent

Rationale: During the latent phase weaker contractions are starting, however pain is minimal. During the active phase contractions become stronger & more frequent, pain relief is needed, & the woman may feel theurge to push or have a BM.

Fill in the blank: A tocotransducer is used (internally OR

externally) to assess uterine contractions during labor.

Answer: internally

Rationale: A tocotransducer (toco) is placed externally on the woman's abdomen

to assess uterine contractions while an intrauterine pressure catheter (IUPC) is used internally for better accuracy.