OB NCLEX INTRAPARTUM NEW SOLUTION 2022 REAL PRACTICE

OB NCLEX INTRAPARTUM NEW SOLUTION 2022 REAL PRACTICE

EXAM QUESTIONS AND ANSWERS COMPLETE GUIDE

When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor?

• Active phase
• Latent phase
• Descent phase
• Transitional phase - 4

In the transitional phase, the cervix dilates from 8 to 10 cm, and intense contractions occur every 1½ to 2 minutes and last for 45 to 90 seconds. In the active phase, the cervix dilates from 5 to 7 cm, and moderate contractions progress to strong contractions that last 60 seconds. In the latent phase, the cervix dilates 3 to 4 cm, and contractions are short, irregular, and mild. No descent phase exists. (Fetal descent may begin several weeks before labor but usually doesn't occur until the second stage of labor.)

During labor, a client asks the nurse why her blood pressure must be measured so often. Which explanation should the nurse provide?

• Blood pressure reflects changes in cardiovascular function, which may affect the

fetus.

• Increased blood pressure indicates that the client is experiencing pain.

• Increased blood pressure signals the peak of the contraction.

4. Medications given during labor affect blood pressure. - Answer: 1

RATIONALES: Frequent blood pressure measurement helps determine whether

maternal cardiovascular function is adequate. During contractions, blood flow to the intervillous spaces changes, compromising fetal blood supply. Increased blood pressure is expected during pain and contractions. Measuring blood pressure frequently helps determine whether blood pressure has returned to precontraction levels, ensuring adequate blood flow to the fetus. Although medications given during labor can affect blood pressure, the main purpose of measuring blood pressure is to verify adequate fetal status.

Because cervical effacement and dilation aren't progressing in a client in labor, the physician orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the client's fluid intake and output closely during oxytocin administration?

• Oxytocin causes water intoxication.
• Oxytocin causes excessive thirst.
• Oxytocin is toxic to the kidneys.

4. Oxytocin has a diuretic effect. - Answer: 1

RATIONALES: The nurse should monitor fluid intake and output because prolonged

oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results from the work of labor and limited oral fluid intake — not oxytocin. Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation?

• Breech position
• Late decelerations
• Entrance into the second stage of labor

4. Multiple gestation - Answer: 1

RATIONALES: Fetal heart sounds in the upper right quadrant and meconium-stained

amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.

A client is admitted to the labor and delivery area. How can the nurse most effectively determine the duration of the client's contractions?

• By timing the period between one contraction and the beginning of the next

contraction

• By timing the period from the onset of uterine tightening to uterine relaxation

• By timing the period from the increment (building-up) phase to the acme (peak)

phase

• By timing the period from the acme (peak) phase to the decrement (letting-down)

phase - Answer: 2

RATIONALES: To determine the duration of contractions, the nurse should time the period from the onset of uterine tightening to uterine relaxation. Timing the period between one contraction and the beginning of the next contraction helps determine the frequency of contractions. Timing the period from the increment to the acme or from the acme to the decrement supplies only partial information about contractions.

A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an I.V. infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her care plan?

• Carefully titrating the oxytocin based on her pattern of labor

• Monitoring vital signs, including assessment of fetal well-being, every 15 to 30

minutes

• Allowing the client to ambulate as tolerated

• Helping the client use breathing exercises to manage her contractions - Answer: 3

RATIONALES: Because the fetus is at risk for complications, frequent and close

monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate.Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include.

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. Who should the nurse manager consult to help the staff cope with this unexpected death?

• The human resource director, so she can arrange vacation time for the staff

• The physician, so he can provide education about HELLP syndrome

• The social worker, so she can contact the family about funeral arrangements and

pass along the information to the nursing staff

• The chaplain, because his educational background includes strategies for handling

grief - Answer: 4

RATIONALES: The chaplain should be consulted because his educational background

provides strategies for helping others handle grief. Providing the staff with vacation isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.

A client with active genital herpes is admitted to the labor and delivery area during the first stage of labor. Which type of birth should the nurse anticipate for this client?

• Mid forceps
• Low forceps
• Induction

4. Cesarean - Answer: 4

RATIONALES: For a client with active genital herpes, cesarean birth helps avoid

infection transmission to the neonate, which would occur during a vaginal birth. Mid forceps and low forceps are types of vaginal births that could transmit the herpes infection to the neonate. Induction is used only during vaginal birth; therefore, it's inappropriate for this client.

When caring for a client who's having her second baby, the nurse can anticipate the client's labor will be which of the following?

• Shorter than her first labor
• About half as long as her first labor
• About the same length of time as her first labor
• A length of time that can't be determined based on her first labor - Answer: 2

RATIONALES: A woman having her second baby can anticipate a labor about half as

long as her first labor. The other options are incorrect.

The nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred?

• Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry
• Acidic pH of fluid when tested with nitrazine paper
• Presence of amniotic fluid in the vagina
• Cervical dilation of 6 cm
• Alkaline pH of fluid when tested with nitrazine paper - 1,3,5 - The fernlike pattern that

occurs when vaginal fluid is placed on a glass slide and allowed to dry, presence of amniotic fluid in the vagina, and alkaline pH of fluid are all signs of ruptured membranes. The fernlike pattern seen when the fluid is allowed to dry on a slide is a result of the high sodium and protein content of the amniotic fluid. The presence of amniotic fluid in the vagina results from the expulsion of the fluid from the amniotic sac.Cervical dilation and regular contractions are signs of progressing labor but don't indicate PROM.

After admission to the labor and delivery area, a client undergoes routine tests, including a complete blood count, urinalysis, Venereal Disease Research Laboratory test, and gonorrhea culture. The gonorrhea culture is positive, although the client lacks signs and symptoms of this disease. What is the significance of this finding?

• Maternal gonorrhea may cause a neural tube defect in the fetus.
• Maternal gonorrhea may cause an eye infection in the neonate.
• Maternal gonorrhea may cause acute liver changes in the fetus.

4. Maternal gonorrhea may cause anemia in the neonate. - Answer: 2

RATIONALES: Gonorrhea in the cervix may cause neonatal eye infection during

delivery as well as a serious puerperal infection in the client. Maternal gonorrhea isn't associated with neural tube defects, acute fetal liver changes, or neonatal anemia.

The nurse observes a late deceleration. It's characterized by and indicates which of the following?

• U-shaped deceleration occurring after the first half of the contraction, indicating

uteroplacental insufficiency

• U-shaped deceleration occurring with the contraction, indicating cord compression