Nursing Labor & Birth Clinical Immersion Q & A, Exams of Nursing

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NURSING 7282

Labor & Birth Clinical

Immersion

Q & A w/ Rationales

1. A 25-year-old primigravida at 39 weeks of gestation is admitted to the labor and delivery unit with regular contractions. Her cervix is 4 cm dilated and 80% effaced. The fetal heart rate (FHR) is 140 beats per minute with moderate variability and no decelerations. The nurse should: a) Prepare for an imminent delivery b) Administer oxytocin to augment labor c) Monitor the FHR and uterine activity continuously d) Perform a vaginal exam every hour to assess progress Answer: c) Monitor the FHR and uterine activity continuously Rationale: The nurse should monitor the FHR and uterine activity continuously to assess the well-being of the fetus and the progress of labor. The FHR pattern is reassuring and indicates adequate oxygenation. The cervix is not fully dilated and there is no indication of fetal distress or maternal complications that would require immediate delivery or augmentation of labor. A vaginal exam every hour is unnecessary and may increase the risk of infection.
2. A 32-year-old multipara at 41 weeks of gestation is undergoing induction of labor with oxytocin. Her cervix is 6 cm dilated and 90% effaced. The FHR is 150 beats per minute with minimal variability and late decelerations. The nurse should: a) Increase the oxytocin infusion rate to hasten delivery b) Decrease the oxytocin infusion rate and administer

d) Document the findings as normal rupture of membranes Answer: b) Assess the color, odor, and amount of amniotic fluid Rationale: The nurse should assess the color, odor, and amount of amniotic fluid after rupture of membranes to determine if there are any signs of infection, meconium staining, or oligohydramnios. Clear fluid indicates normal amniotic fluid without infection or meconium. A foul odor or a greenish or yellowish color may indicate infection or meconium aspiration syndrome. A small amount of fluid may indicate oligohydramnios, which may be associated with fetal growth restriction or renal anomalies. Checking the FHR for signs of cord prolapse is important, but not urgent, as the FHR pattern is reassuring and indicates no cord compression. Palpating the fundus for signs of uterine rupture is unnecessary, as there are no symptoms of uterine rupture such as severe abdominal pain, vaginal bleeding, or loss of fetal station. Documenting the findings as normal rupture of membranes is appropriate, but not a priority action.

4. A 30-year-old multipara at 40 weeks of gestation is in active labor. Her cervix is 10 cm dilated and fully effaced. The FHR is 130 beats per minute with moderate variability and early decelerations. The nurse observes that the fetal head is visible at the introitus with each contraction. The nurse should: a) Encourage the mother to push with each contraction b) Apply gentle pressure to the perineum to prevent tearing c) Support the fetal head and guide it out of the birth canal

d) All of the above Answer: d) All of the above Rationale: The nurse should encourage the mother to push with each contraction to facilitate delivery. The nurse should also apply gentle pressure to the perineum to prevent tearing and support the fetal head and guide it out of the birth canal to prevent injury to the fetus or the mother. The FHR pattern is normal and indicates no fetal distress. Early decelerations are a benign finding that reflect fetal head compression during contractions.

5. A 26-year-old primigravida at 37 weeks of gestation delivers a healthy baby girl after a normal labor and delivery. The nurse places the baby on the mother's chest and observes that the baby is pink, has a strong cry, and is moving all extremities. The nurse should: a) Clamp and cut the umbilical cord b) Assign an Apgar score of 10 c) Initiate breastfeeding d) Dry and warm the baby Answer: d) Dry and warm the baby Rationale: The nurse should dry and warm the baby to prevent heat loss and stimulate breathing. The baby has a high Apgar score of 10, which means that she is in excellent condition and does not need any resuscitation. Clamping and cutting the umbilical cord can be delayed until it stops pulsating or for at least one minute after birth to allow for optimal placental transfusion. Initiating breastfeeding can be done after drying and warming the baby, as it promotes bonding, colostrum intake, and uterine

3. A primigravida is in active labor and requests an epidural for pain relief. Before administering the epidural, it is most important for the nurse to: a) Assess the mother's blood pressure b) Assess fetal heart rate c) Administer intravenous fluid bolus d) Obtain informed consent Answer: a) Assess the mother's blood pressure Rationale: It is crucial to assess the mother's blood pressure before administering an epidural to ensure stability and identify any contraindications.
4. Which of the following is a sign of placental separation during the third stage of labor? a) Increase in blood pressure b) Uterus becomes firm and globular c) Sudden decrease in vaginal bleeding d) Fetal head emerges Answer: b) Uterus becomes firm and globular Rationale: The uterus becomes firm and globular due to uterine contraction and placental separation during the third stage of labor.
5. A pregnant woman arrives at the hospital at 7 cm cervical dilation, and the nurse notes prolapsed umbilical cord upon examination. What should be the immediate nursing action?

a) Administer oxygen to the mother b) Prepare the mother for immediate cesarean section c) Push gently on the fetal presenting part during contractions d) Elevate the mother's hips and legs Answer: d) Elevate the mother's hips and legs Rationale: Elevating the mother's hips and legs helps alleviate pressure on the prolapsed umbilical cord and prevents fetal compromise until further interventions can be implemented.

6. Which medication is commonly administered during the active phase of labor to promote uterine contractions? a) Oxytocin (Pitocin) b) Misoprostol (Cytotec) c) Nifedipine (Procardia) d) Magnesium sulfate Answer: a) Oxytocin (Pitocin) Rationale: Oxytocin is commonly administered to induce or augment labor by promoting regular uterine contractions.
7. In the first stage of labor, the nurse should monitor the parturient for signs of fetal distress. Which sign would require immediate intervention? a) Fetal heart rate of 160 bpm b) Meconium-stained amniotic fluid c) Increase in maternal blood pressure

Rationale: The T in EFM stands for telemetry monitoring, which refers to the wireless transmission of fetal heart rate and uterine contraction patterns.

10. A laboring woman is experiencing prolonged labor and signs of maternal exhaustion. Which intervention is appropriate in this situation? a) Administering an epidural for pain relief b) Suggesting an immediate cesarean section c) Encouraging the woman to push forcefully during contractions d) Providing a brief period of rest and nutrition Answer: d) Providing a brief period of rest and nutrition Rationale: Prolonged labor can lead to maternal exhaustion. Providing a brief period of rest and nutrition can help replenish energy and improve maternal stamina for labor continuation.
11. A primigravida in active labor has received epidural anesthesia and suddenly develops hypotension. What is the most appropriate nursing action? a) Administering oxygen to the mother b) Increasing the epidural infusion rate c) Positioning the mother in a supine position d) Elevating the mother's lower extremities Answer: d) Elevating the mother's lower extremities Rationale: Elevating the mother's lower extremities can help improve blood flow and relieve the hypotension

caused by the epidural anesthesia.

12. A nurse is assessing a newborn infant immediately after birth. Which finding would be a cause for concern? a) Heart rate of 110 bpm b) Respiratory rate of 60 breaths per minute c) Body temperature of 99.5°F (37.5°C) d) Acrocyanosis of the extremities Answer: b) Respiratory rate of 60 breaths per minute Rationale: A respiratory rate of 60 breaths per minute in a newborn immediately after birth is higher than the expected range. This finding may indicate respiratory distress and requires further evaluation.
13. After delivery, the nurse observes excessive uterine bleeding and suspects uterine atony. Which intervention should the nurse prioritize? a) Administering uterotonic medication (e.g., oxytocin) b) Initiating continuous fetal monitoring c) Assisting with immediate neonatal resuscitation d) Checking blood pressure and oxygen saturation Answer: a) Administering uterotonic medication (e.g., oxytocin) Rationale: Uterine atony can lead to excessive uterine bleeding. Administering a uterotonic medication such as oxytocin helps promote uterine contraction and control bleeding.

C:

Question: During the active phase of labor, which maternal vital sign should the nurse prioritize monitoring? A. Blood pressure B. Respiratory rate C. Pulse oximetry D. Temperature Answer: D. Temperature Rationale: Monitoring maternal temperature is crucial during the active phase of labor to detect signs of infection, specifically chorioamnionitis, which can have serious implications for both the mother and the baby. Question: A laboring woman experiences prolonged decelerations in fetal heart rate. What should the nurse prioritize assessing first? A. Maternal blood pressure B. Fetal scalp pH C. Maternal oxygen saturation D. Fetal movement Answer: B. Fetal scalp pH Rationale: Prolonged decelerations in fetal heart rate may indicate fetal distress. Assessment of fetal scalp pH provides valuable information about the acid-base status of the fetus, guiding timely interventions. Question: Which maternal position is most suitable for a woman in the second stage of labor with persistent occiput

posterior fetal position? A. Supine with legs elevated B. Left lateral C. Squatting D. Hands and knees Answer: D. Hands and knees Rationale: Encouraging the woman to assume a hands and knees position can facilitate fetal rotation, potentially alleviating the persistent occiput posterior position and reducing the risk of prolonged labor. Question: The nurse is assessing a woman in early labor and notes ruptured membranes with clear amniotic fluid and umbilical cord visible at the vaginal introitus. What is the priority action? A. Performing a sterile speculum examination B. Placing the woman in a knee-chest position C. Preparing for immediate cesarean birth D. Pushing the umbilical cord back into the vagina Answer: B. Placing the woman in a knee-chest position Rationale: Placing the woman in a knee-chest position can alleviate cord compression, providing immediate relief while preparing for emergent interventions. Question: A woman in active labor reports sudden rectal pressure and a strong urge to push. What should the nurse prioritize assessing before allowing the woman to push? A. Fetal heart rate B. Cervical dilation C. Maternal blood pressure

Question: A postpartum woman exhibits signs of excessive bleeding and hypovolemic shock. What intervention should the nurse prioritize? A. Administering intravenous oxytocin B. Initiating a blood transfusion C. Elevating the woman's legs D. Assisting with fundal massage Answer: A. Administering intravenous oxytocin Rationale: Administering intravenous oxytocin is the priority intervention to stimulate uterine contractions and control postpartum hemorrhage. Question: A newborn displays signs of respiratory distress shortly after birth. What should the nurse prioritize assessing first? A. Heart rate B. Skin color C. Capillary refill time D. Temperature Answer: A. Heart rate Rationale: Assessment of the newborn's heart rate is critical to determine the severity of respiratory distress and guide appropriate interventions. Question: A woman in active labor with a history of herpes simplex virus (HSV) presents with genital lesions. What intervention should the nurse prioritize? A. Initiating antiviral therapy B. Applying topical silver sulfadiazine

C. Isolating the woman in a negative pressure room D. Administering prophylactic antibiotics Answer: A. Initiating antiviral therapy Rationale: Initiating antiviral therapy is essential to manage active HSV lesions and reduce the risk of perinatal transmission to the newborn. Question: A woman in the second stage of labor experiences a nuchal cord. What intervention should the nurse prioritize? A. Clamping and cutting the umbilical cord B. Encouraging maternal pushing efforts C. Performing immediate vaginal examination D. Attempting to slip the cord over the fetal head Answer: D. Attempting to slip the cord over the fetal head Rationale: Attempting to slip the nuchal cord over the fetal head can alleviate cord compression and prevent adverse fetal outcomes. Question: A laboring woman with preeclampsia develops seizures. What intervention should the nurse prioritize? A. Administering magnesium sulfate B. Initiating therapeutic hypothermia C. Preparing for emergent cesarean birth D. Providing intravenous vasopressors Answer: A. Administering magnesium sulfate Rationale: Administering magnesium sulfate is the priority intervention to prevent and manage seizures in women with preeclampsia.

C. Initiating thrombolytic therapy D. Preparing for urgent cardiac catheterization Answer: A. Administering oxygen therapy Rationale: Administering oxygen therapy is the priority intervention to alleviate hypoxemia and improve the woman's respiratory status while further interventions are initiated.