LVN Maternal and Newborn Nursing 2 — Questions and Answers
Question 1: During active labor, how frequently should a nurse assess contractions and fetal heart rate for a low-risk patient?
- Every 5 minutes
- Every 15–30 minutes (Correct answer)
- Every hour
- Every 2 hours
Correct answer: Every 15–30 minutes
AWHONN guidelines recommend assessing FHR and contractions every 15–30 minutes during active labor for low-risk patients.
Question 2: A patient in the transition phase of labor (8–10 cm dilated) reports a strong urge to push. What is the nurse's priority action?
- Encourage the patient to begin pushing immediately
- Assess cervical dilation before allowing the patient to push (Correct answer)
- Administer oxytocin to accelerate delivery
- Prepare the patient for an emergency cesarean section
Correct answer: Assess cervical dilation before allowing the patient to push
Complete dilation (10 cm) must be confirmed before pushing; pushing on an incompletely dilated cervix can cause lacerations and complications.
Question 3: Which medication is routinely administered after delivery of the placenta to prevent postpartum hemorrhage?
- Magnesium sulfate
- Terbutaline
- Oxytocin (Pitocin) (Correct answer)
- Betamethasone
Correct answer: Oxytocin (Pitocin)
Oxytocin is the first-line uterotonic agent given immediately after placental delivery to stimulate uterine contraction and prevent hemorrhage.
Question 4: During a postpartum assessment, the nurse finds the fundus is boggy and displaced to the right of midline. What is the most likely cause?
- Uterine atony
- A full bladder (Correct answer)
- Retained placental fragments
- Uterine infection
Correct answer: A full bladder
A full bladder is the most common cause of a boggy, displaced fundus because the distended bladder pushes the uterus out of midline and prevents contraction.
Question 5: Which description best defines late decelerations on an electronic fetal monitor tracing?
- FHR decreases at the onset of a contraction and returns to baseline at the contraction's end
- FHR decreases that mirror contractions with no lag time
- FHR decreases beginning after the peak of a contraction and recovering after the contraction ends (Correct answer)
- Abrupt FHR decreases unrelated to contractions
Correct answer: FHR decreases beginning after the peak of a contraction and recovering after the contraction ends
Late decelerations are gradual FHR decreases that begin after the acme of a contraction and return to baseline after the contraction ends, signaling uteroplacental insufficiency.
Question 6: A newborn at 1 minute has a heart rate of 102, weak cry, some muscle flexion, a grimace to stimulation, and a pink body with blue extremities. What is the APGAR score?
- 5
- 6 (Correct answer)
- 7
- 8
Correct answer: 6
Heart rate ≥100=2, weak cry=1, some flexion=1, grimace=1, acrocyanosis (pink body/blue extremities)=1, totaling an APGAR score of 6.
Question 7: What is the most common cause of postpartum hemorrhage (PPH)?
- Uterine atony (Correct answer)
- Cervical lacerations
- Retained placental fragments
- Coagulation disorders
Correct answer: Uterine atony
Uterine atony—failure of the uterus to contract after delivery—accounts for approximately 80% of all postpartum hemorrhage cases.
LVN Maternal and Newborn Nursing 2
During active labor, how frequently should a nurse assess contractions and fetal heart rate for a low-risk patient?