1. A client is admitted to the birthing suite in early active labor.

The priority
nursing intervention on the admission of this client would be:
A. Auscultating the fetal heart
B. Taking an obstetric history
C. Asking the client when she last ate
D. Ascertaining whether the membranes were ruptured

Correct Answer: A. Auscultating the fetal heart.

Determining the fetal well-being supersedes all other measures. If the FHR is
absent or persistently decelerating, immediate intervention is required. During
labor, cardiotocographic monitoring is often employed to monitor uterine
contractions and fetal heart rate over time. Clinicians monitor fetal heart tracings
to evaluate for any signs of fetal distress that would warrant intervention as well
as the adequacy or inadequacy of contractions.

2. A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100%

effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is
aware that the fetus’ head is:
A. Not yet engaged
B. Entering the pelvic inlet
C. Below the ischial spines
D. Visible at the vaginal opening

Correct Answer: C. Below the ischial spines

A station of +1 indicates that the fetal head is 1 cm below the ischial spines.
Positive numbers are used when a baby has descended beyond the ischial spines.
During birth, a baby is at the +4 to +5 station.

3. After doing Leopold’s maneuvers, the nurse determines that the fetus is in
the ROP position. To best auscultate the fetal heart tones, the Doppler is
placed:
A. Above the umbilicus at the midline
B. Above the umbilicus on the left side
C. Below the umbilicus on the right side
D. Below the umbilicus near the left groin
Correct Answer: C. Below the umbilicus on the right side
Fetal heart tones are best auscultated through the fetal back; because the
position is ROP (right occiput presentation), the back would be below the
umbilicus and on the right side.

4. The physician asks the nurse the frequency of a laboring client’s contractions.
The nurse assesses the client’s contractions by timing from the beginning of one
contraction:

A. Until the time it is completely over

B. To the end of a second contraction

C. To the beginning of the next contraction

D. Until the time that the uterus becomes very firm

Correct Answer: C. To the beginning of the next contraction

This is the way to determine the frequency of the contractions. When timing
contractions, start counting from the beginning of one contraction to the
beginning of the next. The easiest way to time contractions is to write down on
paper the time each contraction starts and its duration, or count the seconds the
actual contraction lasts.

5. The nurse observes the client’s amniotic fluid and decides that it appears
normal, because it is:

A. Clear and dark amber in color

B. Milky, greenish yellow, containing shreds of mucus

C. Clear, almost colorless, and containing little white specks

D. Cloudy, greenish-yellow, and containing little white specks

Correct Answer: C. Clear, almost colorless, and containing little white specks.
By 36 weeks gestation, normal amniotic fluid is colorless with small particles of
vernix caseosa present. Amniotic fluid is usually clear to pale yellow in color. It
should be odorless, or slightly sweet in odor—although some say it has a bleach-
like smell.
6. At 38 weeks gestation, a client is having late decelerations. The fetal pulse
oximeter shows 75% to 85%. The nurse should:

A. Discontinue the catheter if the reading is not above 80%.

B. Discontinue the catheter if the reading does not go below 30%.

C. Advance the catheter until the reading is above 90% and continue monitoring.

D. Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring.

Correct Answer: D. Reposition the catheter, recheck the reading, and if it is

55%, keep monitoring.
Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be
between 30% and 70%. 75% to 85% would indicate maternal readings. Fetal pulse
oximetry measures how much oxygen the baby’s blood is carrying. It uses a
probe that sits on the baby’s head whilst in the uterus and vagina during labor.
The probe is said not to interfere with the woman’s mobility during labor.

7. When examining the fetal monitor strip after the rupture of the membranes in
a laboring client, the nurse notes variable decelerations in the fetal heart rate. The
nurse should:

A. Stop the oxytocin infusion

B. Change the client’s position

C. Prepare for immediate delivery

D. Take the client’s blood pressure

Correct Answer: B. Change the client’s position.

Variable decelerations usually are seen as a result of cord compression; a change
of position will relieve pressure on the cord. Variable decelerations can be seen
resulting from the fetal movement if the fetus is premature. In the term fetus,
variable decelerations result from vagus nerve-mediated parasympathetic effects
on the heart. There are several theories regarding the pathway that leads to this
vagal stimulation.
8. When monitoring the fetal heart rate of a client in labor, the nurse identifies an
elevation of 15 beats above the baseline rate of 135 beats per minute lasting for
15 seconds. This should be documented as:

A. An acceleration

B. An early elevation

C. A sonographic motion

D. A tachycardia

Correct Answer: A. An acceleration

An acceleration is an abrupt elevation above the baseline of 15 beats per minute
for 15 seconds; if the acceleration persists for more than 10 minutes it is
considered a change in baseline rate. A tachycardic FHR is above 160 beats per
minute.

9. A laboring client complains of low back pain. The nurse replies that this pain
occurs most when the position of the fetus is:

A. Breech

B. Transverse

C. Occiput anterior

D. Occiput posterior

Correct Answer: D. Occiput posterior

A persistent occiput posterior position causes intense back pain because of fetal
compression of the sacral nerves. Occiput anterior is the most common fetal
position and does not cause back pain.

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

Correct Answer: A. Blowing.

Blowing forcefully through the mouth controls the strong urge to push and
allows for a more controlled birth of the head.

11. During the period of induction of labor, a client should be observed carefully
for signs of:

A. Severe pain

B. Uterine tetany

C. Hypoglycemia

D. Umbilical cord prolapse

Correct Answer: B. Uterine tetany.

Uterine tetany could result from the use of oxytocin to induce labor. Because
oxytocin promotes powerful uterine contractions, uterine tetany may occur. The
oxytocin infusion must be stopped to prevent uterine rupture and fetal
compromise.

12. A client arrives at the hospital in the second stage of labor. The fetus’ head is
crowning, the client is bearing down, and the birth appears imminent. The nurse
should:

A. Transfer her immediately by stretcher to the birthing unit.

B. Tell her to breathe through her mouth and not to bear down.

C. Instruct the client to pant during contractions and to breathe through her
mouth.

D. Support the perineum with the hand to prevent tearing and tell the client to
pant.

Correct Answer: D. Support the perineum with the hand to prevent tearing
and tell the client to pant.
Gentle pressure is applied to the baby’s head as it emerges so it is not born too
rapidly. The head is never held back, and it should be supported as it emerges so
there will be
no vaginal lacerations. It is impossible to push and pant at the same time.

13. A laboring client is to have a pudendal block. The nurse plans to tell the client
that once the block is working, she:

A. Will not feel the episiotomy

B. May lose bladder sensation

C. May lose the ability to push

D. Will no longer feel contractions

Correct Answer: C. May lose the ability to push

A pudendal block is a local anesthetic injection given as a treatment for pain in
the second stage of labor (pushing) just before the delivery of the baby. It is
administered through the vaginal wall and into the pudendal nerve in the pelvis,
providing anesthesia to the perineum. The numbing effect of the pudendal block
may cause the woman to lose the ability to push that is why it is not given when
the baby’s head is too far down in the vagina.

14. Which of the following observations indicates fetal distress?

A. Fetal scalp pH of 7.14

B. Fetal heart rate of 144 beats/minute

C. Acceleration of fetal heart rate with contractions

D. Presence of long-term variability

Correct Answer: A. Fetal scalp pH of 7.14

A fetal scalp pH below 7.25 indicates acidosis and fetal hypoxia. Fetal response to
oxygen deprivation is regulated by the autonomic nervous system, mediated by
parasympathetic and sympathetic mechanisms. The fetus is equipped with
compensatory mechanisms for transient hypoxia during labor, but prolonged,
uninterrupted fetal hypoxia may lead progressively to acidosis with cell death,
tissue damage, organ failure and potentially death.
15. Which of the following fetal positions is most favorable for birth?

A. Vertex presentation

B. Transverse lie

C. Frank breech presentation

D. Posterior position of the fetal head

Correct Answer: A. Vertex presentation

Vertex presentation (flexion of the fetal head) is the optimal presentation for
passage through the birth canal. Toward the end of pregnancy, the fetus moves
into position for delivery. Normally, the position of a fetus is facing rearward
(toward the woman’s back) with the face and body angled to one side and the
neck flexed, and presentation is head first.

16. A laboring client has external electronic fetal monitoring in place. Which of
the following assessment data can be determined by examining the fetal heart
rate strip produced by the external electronic fetal monitor?

A. Gender of the fetus

B. Fetal position

C. Labor progress

D. Oxygenation

Correct Answer: D. Oxygenation

Oxygenation of the fetus may be indirectly assessed through fetal monitoring by
closely examining the fetal heart rate strip. Accelerations in the fetal heart rate
strip indicate good oxygenation, while decelerations in the fetal heart rate
sometimes indicate poor fetal oxygenation.

17. A laboring client is in the first stage of labor and has progressed from 4 to 7
cm in cervical dilation. In which of the following phases of the first stage does
cervical dilation occur most rapidly?
A. Preparatory phase

B. Latent phase

C. Active phase

D. Transition phase

Correct Answer: C. Active phase.

Cervical dilation occurs more rapidly during the active phase than any of the
previous phases. The active phase is characterized by cervical dilation that
progresses from 4 to 7 cm. The active phase of labor should occur much more
rapidly, usually within 4 hours after the rupture of membranes when there are
adequate uterine contractions. If the mother does not fully dilate by these
average estimations, she is said to be having an arrest of the active phase of
Stage 1 labor.

18. 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?

A. Let the client get up to use the potty

B. Allow the client to use a bedpan

C. Perform a pelvic examination

D. Check the fetal heart rate

Correct Answer: C. Perform a pelvic examination

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.

19. Labor is a series of events affected by the coordination of the five essential
factors. One of these is the passenger (fetus). Which are the other four factors?

A. Contractions, passageway, placental position and function, pattern of care.

B. Contractions, maternal response, placental position, psychological response.

 C. Passageway, contractions, placental position, and function, psychological
response.

D. Passageway, placental position, and function, paternal response, psychological

response.

Correct Answer: C. Passageway, contractions, placental position and

function, psychological response.
The five essential factors (5 P’s) are passenger (fetus), passageway (pelvis), powers
(contractions), placental position and function, and psyche (psychological
response of the mother).

20. Fetal presentation refers to which of the following descriptions?

A. Fetal body part that enters the maternal pelvis first.

B. Relationship of the presenting part to the maternal pelvis.

C. Relationship of the long axis of the fetus to the long axis of the mother.

D. A classification according to the fetal part.

Correct Answer: A. Fetal body part that enters the maternal pelvis first.
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.

21. A client is admitted to the L & D suite at 36 weeks’ gestation. She has a
history of C-section and complains of severe abdominal pain that started less
than 1 hour earlier. When the nurse palpates tetanic contractions, the client again
complains of severe pain. After the client vomits, she states that the pain is better
and then passes out. Which is the probable cause of her signs and symptoms?

A. Hysteria compounded by the flu

B. Placental abruption

C. Uterine rupture

D. Dysfunctional labor
Correct Answer: C. Uterine rupture.
Uterine rupture is a medical emergency that may occur before or during labor.
Signs and symptoms typically include abdominal pain that may ease after uterine
rupture, vomiting, vaginal bleeding, hypovolemic shock, and fetal distress. With
placental abruption, the client typically complains of vaginal bleeding and
constant abdominal pain.

22. Upon completion of a vaginal examination on a laboring woman, the nurse

records 50%, 6 cm, -1. Which of the following is a correct interpretation of the
data?

A. Fetal presenting part is 1 cm above the ischial spines.

B. Effacement is 4 cm from completion.

C. Dilation is 50% completed.

D. Fetus has achieved passage through the ischial spines.

Correct Answer: A. Fetal presenting part is 1 cm above the ischial spines.

Station of – 1 indicates that the fetal presenting part is above the ischial spines
and has not yet passed through the pelvic inlet. A station of zero would indicate
that the presenting part has passed through the inlet and is at the level of the
ischial spines or is engaged.

23. Which of the following findings meets the criteria of a reassuring FHR
pattern?

A. FHR does not change as a result of fetal activity.

B. Average baseline rate ranges between 100 – 140 BPM.

C. Mild late deceleration patterns occur with some contractions.

D. Variability averages between 6 – 10 BPM.

Correct Answer: D. Variability averages between 6 – 10 BPM.

Variability indicates a well-oxygenated fetus with a functioning autonomic
nervous system. The FHR is under constant variation from the baseline. This
variability reflects a healthy nervous system, chemoreceptors, baroreceptors and
cardiac responsiveness. Prematurity decreases variability; therefore, there is little
rate fluctuation before 28 weeks. Variability should be normal after 32 weeks.

24. Late deceleration patterns are noted when assessing the monitor tracing of a
woman whose labor is being induced with an infusion of Pitocin. The woman is in
a side-lying position, and her vital signs are stable and fall within a normal range.
Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The
nurse’s immediate action would be to:

A. Change the woman’s position

B. Stop the Pitocin

C. Elevate the woman’s legs

D. Administer oxygen via a tight mask at 8 to 10 liters/minute

Correct Answer: B. Stop the Pitocin

Late deceleration patterns noted are most likely related to alteration in
uteroplacental perfusion associated with the strong contractions described. The
immediate action would be to stop the Pitocin infusion since Pitocin is an
oxytocin which stimulates the uterus to contract.

25. The nurse should realize that the most common and potentially harmful
maternal complication of epidural anesthesia would be:

A. Severe postpartum headache

B. Limited perception of bladder fullness

C. Increase in respiratory rate

D. Hypotension

Correct Answer: D. Hypotension.

Epidural anesthesia can lead to vasodilation and a drop in blood pressure that
could interfere with adequate placental perfusion. The woman must be well
hydrated before and during epidural anesthesia to prevent this problem and
maintain adequate blood pressure.