Maternal Newborn Nursing Test Intrapartum Nursing: Labor and Delivery 2 — Questions and Answers
Question 1: Which assessment finding would indicate a client in labor is experiencing hypotonic uterine dysfunction?
- Contractions less than 25 mmHg in intensity with a frequency of more than every 5 minutes (Correct answer)
- Contractions occurring every 2 minutes with a duration of 90 seconds
- Failure of the presenting part to descend despite adequate contractions
- Cervical dilation of less than 1.2 cm per hour in the active phase
Correct answer: Contractions less than 25 mmHg in intensity with a frequency of more than every 5 minutes
Hypotonic uterine dysfunction is characterized by weak, ineffective contractions (<25 mmHg intensity) that are infrequent, which fail to dilate the cervix adequately.
Question 2: A nurse is preparing to administer oxytocin (Pitocin) for labor augmentation. Which assessment finding requires withholding the medication and notifying the provider?
- Uterine contractions occurring every 2 minutes lasting 90 seconds (Correct answer)
- Fetal heart rate baseline of 140 bpm with moderate variability
- Cervical dilation of 4 cm
- Intact amniotic membranes
Correct answer: Uterine contractions occurring every 2 minutes lasting 90 seconds
Contractions lasting >90 seconds or occurring more frequently than every 2 minutes (uterine tachysystole) are a contraindication to oxytocin administration and require provider notification.
Question 3: Which position is MOST appropriate for a client with a suspected shoulder dystocia during delivery?
- McRoberts maneuver with suprapubic pressure (Correct answer)
- Trendelenburg position
- Left lateral (Sims) position
- Lithotomy position with fundal pressure
Correct answer: McRoberts maneuver with suprapubic pressure
The McRoberts maneuver (hyperflexion of the maternal thighs against the abdomen) combined with suprapubic pressure is the first-line intervention for shoulder dystocia.
Question 4: A nurse notes meconium-stained amniotic fluid at rupture of membranes. What is the priority nursing action?
- Apply continuous electronic fetal monitoring and notify the provider (Correct answer)
- Prepare for immediate cesarean delivery
- Increase IV fluid rate to dilute the amniotic fluid
- Reassure the client that this is a normal finding
Correct answer: Apply continuous electronic fetal monitoring and notify the provider
Meconium-stained fluid may indicate fetal distress and increases the risk for meconium aspiration syndrome; continuous FHR monitoring and provider notification are the priority.
Question 5: What is the primary purpose of an episiotomy during vaginal delivery?
- To enlarge the vaginal opening and prevent severe perineal lacerations in selected cases (Correct answer)
- To routinely speed up delivery in all vaginal births
- To reduce postpartum perineal pain
- To prevent neonatal shoulder dystocia
Correct answer: To enlarge the vaginal opening and prevent severe perineal lacerations in selected cases
Episiotomy enlarges the vaginal outlet to facilitate delivery in specific clinical situations (e.g., fetal distress, shoulder dystocia) and may prevent severe spontaneous lacerations in select cases.
Question 6: What does an acceleration in the fetal heart rate tracing typically indicate?
- Fetal well-being and adequate oxygenation (Correct answer)
- Fetal hypoxia
- Umbilical cord compression
- Uterine tachysystole
Correct answer: Fetal well-being and adequate oxygenation
Accelerations (≥15 bpm above baseline for ≥15 seconds) are a reassuring sign indicating adequate fetal oxygenation and neurological integrity.
