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1 Thisstudysourcewasdownloadedby100000840858457fromCourseHero.comon11-27-202210:42:52GMT-06:00 https://www.coursehero.com/file/63255637/Labor-and-Delivery-NCLEX-Questions-Answersdocx/ AnsweredIntrapartumNCLEXquestions&Answers_Fall

2022/2023.

LaborandDeliveryNCLEXQuestions 1.Thenurseinamaternityunitisreviewingtheclients'records.Whichclientsshouldthenurseidentifyasbeingat themostriskfordevelopingdisseminatedintravascularcoagulation(DIC)?Selectallthatapply.

Rationale:

A.Aprimigravidawithmildpreeclampsia B.Aprimigravidawhodelivereda10-lbinfant3hoursago C.AgravidaIIwhohasjustbeendiagnosedwithdeadfetussyndrome D.AgravidaIVwhodelivered8hoursagoandhaslost500mLofblood E.Aprimigravidaat29weeksofgestationwhowasrecentlydiagnosedwithseverepreeclampsia CandE.Inapregnantclient,DICisaconditioninwhichtheclottingcascadeisactivated,resultingintheformationof clotsinthemicrocirculation.DeadfetussyndromeisconsideredariskfactorforDIC.Severepreeclampsiais consideredariskfactorforDIC;amildcaseisnot.DeliveringalargenewbornisnotconsideredariskfactorforDIC.HemorrhageisariskfactorforDIC;however,alossof500mLisnotconsideredhemorrhage.

2.Thenurseiscaringforaclientinlabor.Whichassessmentfindingsindicatetothenursethattheclientis beginningthesecondstageoflabor?Selectallthatapply.A.Thecontractionsareregular.B.Themembraneshaveruptured.C.Thecervixisdilatedcompletely.D.Theclientbeginstoexpelclearvaginalfluid.E.Thespontaneousurgetopushisinitiatedfromperinealpressure.

Rationale:

CandE.Thesecondstageoflaborbeginswhenthecervixisdilatedcompletelyandendswithbirthoftheneonate.Thewomanhasastrongurgetopushinstage2fromperinealpressure.Options1,2,and4arenotspecific assessmentfindingsofthesecondstageoflaborandoccurinstage1.

3.Thenurseinthelaborroomiscaringforaclientintheactivestageofthefirstphaseoflabor.Thenurseis assessingthefetalpatternsandnotesalatedecelerationonthemonitorstrip.Whatisthemostappropriate nursingaction?A.Administeroxygenviafacemask.B.Placethemotherinasupineposition.C.Increasetherateoftheoxytocinintravenousinfusion.D.Documentthefindingsandcontinuetomonitorthefetalpatterns.

Rationale:

A.Latedecelerationsareduetouteroplacentalinsufficiencyandoccurbecauseofdecreasedbloodflowandoxygen tothefetusduringtheuterinecontractions.Hypoxemiaresults;oxygenat8to10L/minuteviafacemaskisnecessary.Thesupinepositionisavoidedbecauseitdecreasesuterinebloodflowtothefetus.Theclientshouldbeturnedonto hersidetodisplacepressureofthegraviduterusontheinferiorvenacava.Anintravenousoxytocininfusionis

2 Thisstudysourcewasdownloadedby100000840858457fromCourseHero.comon11-27-202210:42:52GMT-06:00 https://www.coursehero.com/file/63255637/Labor-and-Delivery-NCLEX-Questions-Answersdocx/ discontinuedwhenalatedecelerationisnoted.Theoxytocinwouldcausefurtherhypoxemiabecauseofincreased uteroplacentalinsufficiencyresultingfromstimulationofcontractionsbythismedication.Althoughthenursewould documenttheoccurrence,option4woulddelaynecessarytreatment.

3 Thisstudysourcewasdownloadedby100000840858457fromCourseHero.comon11-27-202210:42:52GMT-06:00 https://www.coursehero.com/file/63255637/Labor-and-Delivery-NCLEX-Questions-Answersdocx/ 4.Thenurseisperforminganassessmentofaclientwhoisscheduledforacesareandeliveryat39weeksof gestation.Whichassessmentfindingindicatestheneedtocontactthehealthcareprovider(HCP)?A.Hemoglobinof11g/dL(110mmol/L) B.Fetalheartrateof180beats/minute C.Maternalpulserateof85beats/minute D.Whitebloodcellcountof12,000mm 3

(12.0×10

9 /L)

Rationale:

B.Anormalfetalheartrateis110to160beats/minute.Afetalheartrateof180beats/minutecouldindicate fetaldistressandwouldwarrantimmediatenotificationoftheHCP.Byfullterm,anormalmaternalhemoglobin rangeis11–13g/dL(110–130mmol/L))becauseofthehemodilutioncausedbyanincreaseinplasmavolume duringpregnancy.Thematernalpulserateduringpregnancyincreases10to15beats/minuteoverprepregnancy readingstofacilitateincreasedcardiacoutput,oxygentransport,andkidneyfiltration.Whitebloodcellcountsin anormalpregnancybegintoincreaseinthesecondtrimesterandpeakinthethirdtrimester,withanormalrange of11,000to15,000mm 3 (11to15x10 9 /L),upto18,000mm 3 (18x10 9 /L).Duringtheimmediatepostpartum period,thewhitebloodcellcountmaybe25,000to30,000mm 3 (25to30x10 9 /L)becauseofincreased leukocytosisthatoccursduringdelivery.

5.Aclientarrivesatabirthingcenterinactivelabor.Followingexamination,itisdeterminedthathermembranes arestillintactandsheisata–2station.Thehealthcareproviderpreparestoperformanamniotomy.Whatwill thenurserelaytotheclientasthemostlikelyoutcomesoftheamniotomy?Selectallthatapply.A.Lesspressureonhercervix B.Decreasednumberofcontractions C.Increasedefficiencyofcontractions D.Theneedforincreasedmaternalbloodpressuremonitoring E.Theneedforfrequentfetalheartratemonitoringtodetectthepresenceofaprolapsedcord

Rationale:

CandE.Amniotomy(artificialruptureofthemembranes)canbeusedtoinducelaborwhentheconditionofthe cervixisfavorable(ripe)ortoaugmentlaboriftheprogressbeginstoslow.Rupturingofthemembranesallowsthe fetalheadtocontactthecervixmoredirectlyandmayincreasetheefficiencyofcontractions.Increasedmonitoringof maternalbloodpressureisunnecessaryfollowingthisprocedure.Thefetalheartrateneedstobemonitored frequently,asthereisanincreasedlikelihoodofaprolapsedcordwithrupturedmembranesandahighpresenting part.

6.Aclientinlaboristransportedtothedeliveryroomandpreparedforacesareandelivery.Aftertheclientis transferredtothedeliveryroomtable,thenurseshouldplacetheclientinwhichposition?

Rationale:

A.Supinepositionwithawedgeundertherighthip B.Trendelenburg'spositionwiththelegsinstirrups C.Pronepositionwiththelegsseparatedandelevated D.SemiFowler'spositionwithapillowundertheknees A.Venacavaanddescendingaortacompressionbythepregnantuterusimpedesbloodreturnfromthelowertrunk

4 Thisstudysourcewasdownloadedby100000840858457fromCourseHero.comon11-27-202210:42:52GMT-06:00 https://www.coursehero.com/file/63255637/Labor-and-Delivery-NCLEX-Questions-Answersdocx/ andextremities.Thisleadstodecreasingcardiacreturn,cardiacoutput,andbloodflowtotheuterusand subsequentlythefetus.Thebestpositiontopreventthiswouldbeside-lying,withtheuterusdisplacedoffthe abdominalvessels.Positioningforabdominalsurgerynecessitatesasupineposition,however;awedgeplacedunder therighthipprovidesdisplacementoftheuterus.Trendelenburg'spositionplacespressurefromthepregnantuterus onthediaphragmandlungs,decreasingrespiratorycapacityandoxygenation.AproneorsemiFowler'spositionis notpracticalforthistypeofabdominalsurgery.

7.Thenurseisreviewingtrueandfalselaborsignswithamultiparousclient.Thenursedeterminesthattheclient understandsthesignsoftruelaborifshemakeswhichstatement?A."Iwon'tbeinlaboruntilmybabydrops." B."Mycontractionswillbefeltinmyabdominalarea." C."MycontractionswillnotbeaspainfulifIwalkaround.” D."Mycontractionswillincreaseindurationandintensity."

Rationale:

D.Truelaborispresentwhencontractionsincreaseindurationandintensity.Lighteningordroppingleadsto engagement(presentingpartreachestheleveloftheischialspine)andoccurswhenthefetusdescendsintothepelvis about2weeksbeforedelivery.Contractionsfeltintheabdominalareaandcontractionsthateasewithwalkingare signsoffalselabor.

8.Thenurseinalaborroomispreparingtocareforaclientwithhypertonicuterinecontractions.Thenurseistold thattheclientisexperiencinguncoordinatedcontractionsthatareerraticintheirfrequency,duration,and intensity.Whatistheprioritynursingaction?

Rationale:

A.Providepainreliefmeasures.B.Preparetheclientforanamniotomy.C.Promoteambulationevery30minutes.D.Monitortheoxytocininfusionclosely.A.Hypertonicuterinecontractionsarepainful,occurfrequently,andareuncoordinated.Managementofhypertonic labordependsonthecause.Reliefofpainistheprimaryinterventiontopromoteanormallaborpattern.An amniotomyandoxytocininfusionarenottreatmentmeasuresforhypertoniccontractions;however,thesetreatments maybeusedinclientswithhypotonicdysfunction.Aclientwithhypertonicuterinecontractionswouldnotbe encouragedtoambulateevery30minutes,butwouldbeencouragedtorest.

9.Thematernitynurseiscaringforaclientwithabruptioplacentaeandismonitoringherfordisseminated intravascularcoagulation(DIC).Whichassessmentfindingsaremostlikelyassociatedwithdisseminated intravascularcoagulation?Selectallthatapply.A.Petechiae B.Hematuria C.Increasedplateletcount D.Prolongedclottingtimes E.Oozingfrominjectionsites F.Swellingofthecalfof1leg

Rationale:

A,B,D,andE.DICisastateofdiffuseclottinginwhichclottingfactorsareconsumed,leadingtowidespreadbleeding.Plateletsaredecreasedbecausetheyareconsumedbytheprocess.Coagulationstudiesshownoclotformation(and arethusnormaltoprolonged),andfibrinplugsmayclogthemicrovasculaturediffuselyratherthaninanisolated