Maternal Newborn Nursing Test Intrapartum Nursing: Labor and Delivery 1 — Questions and Answers
Question 1: A client in active labor has a fetal heart rate (FHR) baseline of 170 bpm for 15 minutes. Which nursing action is the priority?
- Notify the provider immediately (Correct answer)
- Reposition the client to the left lateral position
- Administer oxygen via face mask at 8–10 L/min
- Increase IV fluid rate
Correct answer: Notify the provider immediately
A baseline FHR above 160 bpm for ≥10 minutes is tachycardia and requires immediate provider notification to evaluate for infection, fetal distress, or medication effects.
Question 2: Which finding during the second stage of labor indicates the nurse should prepare for an imminent delivery?
- Crowning of the fetal head (Correct answer)
- Rupture of membranes
- Complete cervical dilation
- Increased bloody show
Correct answer: Crowning of the fetal head
Crowning, where the largest diameter of the fetal head is visible at the vaginal introitus without retraction between contractions, signals that delivery is imminent.
Question 3: A client at 39 weeks reports regular contractions every 4 minutes lasting 60 seconds. Cervical exam shows 5 cm dilation, 80% effacement, and -1 station. What stage and phase of labor is she in?
- First stage, active phase (Correct answer)
- First stage, latent phase
- Second stage
- Transition phase
Correct answer: First stage, active phase
Active phase of the first stage of labor is defined by cervical dilation from 6 cm, but 5 cm with regular contractions and significant effacement is consistent with active labor in many clinical frameworks.
Question 4: During labor, a nurse notes variable decelerations on the fetal monitor. What is the first nursing intervention?
- Change the maternal position (Correct answer)
- Apply oxygen via face mask
- Stop oxytocin infusion
- Perform a vaginal exam
Correct answer: Change the maternal position
Variable decelerations are caused by umbilical cord compression; repositioning the mother alleviates cord compression and is always the first intervention.
Question 5: What does a late deceleration pattern on the fetal monitor indicate?
- Uteroplacental insufficiency (Correct answer)
- Umbilical cord compression
- Fetal head compression
- Normal vagal response
Correct answer: Uteroplacental insufficiency
Late decelerations reflect decreased placental perfusion and uteroplacental insufficiency, which reduces fetal oxygenation during uterine contractions.
Question 6: A nurse is assessing a client in labor and notes the umbilical cord is visible at the vaginal introitus. Which action should be taken FIRST?
- Apply continuous upward pressure on the presenting part to relieve cord compression (Correct answer)
- Call for emergency assistance immediately
- Place the client in Trendelenburg position
- Administer oxygen via face mask
Correct answer: Apply continuous upward pressure on the presenting part to relieve cord compression
Umbilical cord prolapse is an obstetric emergency; the nurse must manually elevate the presenting part off the cord to relieve compression while calling for help and preparing for emergency delivery.
