1. The nurse discusses Labor and delivery with a couple.

Which one of the following

designations most accurately describes the position of the baby during delivery when
the face is direct toward the physician’s right hand and the front part of the pregnant
woman?
- LOP (Left occipito-posterior)
2. Which of the following characteristics of contractions would the nurse expect to find
in a client experiencing true labour?
- Increasing intensity with walking
3. During which of the following stages of labor would the nurse assess “crowning”?
- Second stage
4. Which of the following nursing intervention would the nurse perform during the third
stage of labor?
- Promote parent-newborn interaction
5. Immediately before expulsion, which of the following cardinal movements occur?
- External rotation
6. Which of the following would the nurse expect to find when assessing a client who
delivered a newborn 12 hours ago?
- Soft, boggy fundus
7. When teaching a postpartum client about breast-related changes in the immediate
postpartum period, on which of the following would the nurse base the teaching plan?
- Colostrum, present by 2 to 3 postpartum days, eventually changes to breastmilk
8. Which of the following describes the rationale for preventing over distention of the
bladder?
- A full bladder will displace the uterus and may cause postpartum haemorrhage
9. Which of the following factors most influences the new mother’s successful transition
to parenthood?
- The new mother understanding the signs and symptoms of “postpartum blues” and
being able to deal with them
10. According to Rubin, during which of the following periods would the new mother
frequently review her labour and delivery experience?
- Taking- in
11. Which of the following additional assessment findings would be most suspicious and
lead the nurse to suspect postpartum “blues” in a client who is anxious and crying?
- Mood swings, irritability, loss of appetite, difficulty sleeping
12. When assessing lochia serosa, which of the following would the nurse expect?
- Brownish to pinkish
13. After teaching a client about danger signs and symptoms to report to the doctor,
which of the following client statements indicates the need for additional teaching?
- “My vaginal discharge should be bright red for several days”
14. Which of the following would the nurse identify as the underlying cause for
development of haemorrhoids in the early postpartum period?
- Slowed return of GI motility
15. Before assessing the postpartum client’s uterus for firmness and position in relation to
the umbiculus and midline, which of the following should the nurse do first?
- Assist the client to urinate
16. When caring for a client in the postpartum “taking-in” psychosocial adaptation phase,
the nurse should plan to do which of the following?
- Provide nourishment and rest
17. Ms. Faryao is told that lightening has occurred. Lightning, a typical sign of
approaching labor late in pregnancy, is best described as:
- Setting of the fetal head into the pelvis
18. Which of the following should the nurse do when a breast- feeding primipara tells the
nurse that she has engorged breast?
- Tell her to breast-feed more frequently
19. During assessment of the perineum, the nurse identifies 3 medium- blue, soft, painful
haemorrhoids. Which of the following would be the nurse’s best initial action?
- Encourage the client to use the sitz bath
20. The nurse assesses the vital signs of a client 4 hours postpartum. They are as follows;
BP- 90/60; temperature 37.5 C; pulse 100 weak, thready; respiration 20 per minute.
Which of the following should the nurse do first?
- Assess the uterus for firmness and position
21. The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which
of the following assessments would warrant notification of the physician?
- A bright red discharge 5 days after delivery
22. A postpartum client has a temperature of 37.5C, with a uterus that is tender when
palpated, remains unusually large, and is not descending as normally expected. Which
of the following should the nurse assess next?
- Lochia
23. A nurse midwife is performing an assessment of a pregnant patient for the presence of
ballotement. Which of the following would the nurse implement to test for the
presence of ballotement?
- Assessing the cervix for thinning
24. The home health nurse visits a client 3 weeks after delivery. The single mother cries
and tells the nurse, “I just can’t seem to be able to take care of myself and the baby,
too. I’m not a good mother. The baby cries a lot and gets on my nerves! I’m always so
sad and irritable!” Which of the following would be most appropriate?
- Ineffective individual coping
25. Ms. Paragas asks what makes a Labor start. The nurse should base her response on
knowledge that is theorized an increase in all of the following secretions in the body
play a role in initiating the onset of labor except for the secretion of:
- Oxytocin
26. The physician documented gynecoid pelvis after pelvic exam of a client. The nurse
knows that this refers to which of the following?
- A typical female pelvis with a rounded inlet
27. Ms. Saldua asks how long she will be in labor. All of the following factors will
influence the length of Labor except:
- Size of the placenta
28. Ms. Montilla says, “The doctor told her that the baby is at “plus one”. What does that
mean?” The nurse correctly explains that the point to which the baby has descended
during labor is described as a station; when the station is “plus one,” the part of the
baby to be born first is located one
- Fingerbreadth below the ischial spines
29. One hour after delivery, assessment reveals the client’s uterus is one fingerbreadth
below the umbiculus and deviated to the right of midline. Which of the following
would the nurse’s priority action at this time?
- Assist the mother to void
30. The amniotic fluid of a client has greenish tint. The nurse interprets this to be the
result of which of the following?
- Meconium
31. In the third stage of labor, which of the following is the first sign (Calkin’s sign) of
placental separation?
- The uterus rises in the abdomen & becomes firm and globular in shape
32. Following the birth of the baby, the client’s uterine fundus is soft, midline, 2cm above
the umbilicus, and she has saturated two pads within 30 mins. The nurse knows the
client’s condition shows that she has immediate need to.
- Have her fundus massaged
33. The nurse is caring for a woman in labor. The woman is irritable, complains of nausea
and vomits, and has heavier show, and the membranes rupture. The nurse understands
that this indicates that?
- The woman is in transition stage of labor
34. A client has uneventful labor and delivery, after a 7 hours labor she delivers a baby
girl spontaneously. 2 hours after delivery, the nurse finds that the client’s fundus is
firm, shifted to the right, and 2 fingers above the umbilicus, this would indicate:
- A normal process
35. Which of the following describes pattern labor?
- Labor begins after 20 weeks gestation and before 37 weeks gestation
36. Which of the following should the nurse know that a client has begun the transitional
phase of labor?
- Complains of severe pains in the back
37. Shortly following delivery, the client says she feels like she is bleeding. On checking
the fundus the nurse finds a steady trickling of blood from the vagina. Which of the
following action should the nurse do first?
- Hold the fundus firmly and massage it gently
38. While checking the client’s fundus 2 days after postpartum, the nurse observes that it
is in the umbilicus and displaced to the right. This means that the client probably has?
- A full, over distended bladder
39. A client delivers a healthy baby girl. The nurse plans the postpartum care based on the
knowledge that, which of the following?
- The 1st 48 hours postpartum are the most stressful on the cardiopulmonary system
40. What is the fetal lie if the long axis of the fetus is at a right angle diagonal to the long
axis of the mother?
- Transverse/horizontal lie
41. The client begins to experience contractions 2-3 minutes apart that last about 45
seconds. Between contractions, the nurse records a FHR of 100 beats per minute. The
nurse should:
- Notify the physician immediately
42. The fetus is lying perpendicular to the long axis of the mother and the shoulder is the
presenting part. What will be employed to effect delivery?
- Caesarian section
43. Labor is extended and more painful if position is right occipito posterior or left
occipito posterior because:
- Rotation of the fetal head puts pressure on cervix
44. A client admitted to the labor area, she has had no antepartal care, and her membranes
ruptured in the car on the way to the hospital. Which of the following initial nursing
assessments would be least important during her admission?
- Type of anaesthesia requested for delivery
45. The admitting vaginal exam reveals that her cervix is 6cm dilated and 100% effaced.
The fetus is at 1+ station and left occiput anterior. She is having difficulty coping with
her contractions, which are occuring every 3 minutes. Which of these nursing actions
is appropriate during her next contraction?
- Provide direct coaching using chest-abdominal breathing techniques
46. The nurse knows that the client is in the transition phase of labor when she?
- Becomes irritable and frightened
47. The client is in the transitional phase of labor. Her contractions are lasting 75 seconds
and occurring q 2mins. She begins to grunt and says she has to push. Upon vaginal
exam, the nurse finds her cervix is dilated 9 cm. What is the most appropriate nursing
action?
- Explain the pushing will cause the cervix to swell and delay dilation
48. What is the fetal attitude if the fetus’ spinal column is bowed forward; head is flexed
forward; chin touches the sternum; arms are flexed and folded on the chest, the thighs
are flexed onto the abdomen; the calves are pressed against the posterior aspect of the
thighs?
- Complete flexion
49. The client has uneventful vaginal delivery with midline episiotomy done under local
anaesthesia. During the fourth stage of labor, the nurse should include which of the
following in the nursing care plan?
- Palpate the uterus to check muscle tone every 15 mins
50. Ms. Tiglao has just delivered a 3.5kgs baby girl. In assessing the client immediately
after delivery, which of the following would the nurse most likely to find?
- Fundus located halfway between the symphysis pubis and umbilicus, lochia rubra
51. Mrs. Elemos is having vaginal bleeding of bright red blood that is continuously
trickling from the vagina. Her fundus is firm and in the midline. What is most like
cause of this bleeding?
- Laceration
52. Which of the following conditions predispose a client to postpartum haemorrhage
- Caesarean birth
53. Lorhen asks the nurse which fetal position and presentation are ideal?
- Right occipitoanterior with full flexion
54. The nurse is giving exercise guidelines for Labor preparation to a mother’s class. All
are true but one:
- To rise from the floor, roll over the side first and then push up to avoid strain on the
abdominal muscles.
55. Which of the following most likely indicates that the third stage of labor is coming to
an end?
- There is a gush of blood from the vagina and the cord lengthens.
56. Susan delivered her first baby boy 24 hours ago. She had normal vaginal delivery
with midline episiotomy and is breastfeeding her baby. Instructions to her regarding
care of the perineal area should include which of the following?
- Cleanse the perineum with soap and tap water after elimination.
57. The nurse is assessing the lochia on a 1-day post partum patient. The nurse notes that
the lochia is red and has a foul-smelling odor. The nurse determines that this
assessment finding is:
- Indicates the presence of infection
58. Which of the following behavior would indicate Misigina is in the taking hold phase
of postpartum period?
- Requesting the nurse to return the baby to the nursery immediately after feeding
59. Kayla complains of backaches. Which one of the following exercise should the nurse
recommend as most helpful to relieve backaches during pregnancy?
- Pelvic rock
60. Cardinal asks how much blood is she likely to lose during delivery. The maximum
blood loss during delivery that is to be considered to be within normal limits is
approximately:
- 500 ml
61. At the beginning of Blessing’s labor, a moderate increase in the amount of bloody
vaginal discharge (“show”) should be assessed by the nurse as indication of
- Premature separation of the placenta
62. A nurse in a labour room is performing a vaginal assessment on a pregnant client in
labour. The nurse notes the presence of umbilical cord protruding from the vagina.
Which of the following is the initial nursing action
- Place the client in Trendelenburg’s position.
63. A nurse is preparing to assess the uterine fundus of a client in the immediate
postpartum period. When the nurse locates the fundus, she notes that the uterus feels
soft and boggy. Which nursing intervention would be appropriate initially?
- Massage the fundus until firm
64. Which of the following complication is most likely responsible for a delayed
postpartum hemorrhage?
- Uterine subinvolution
65. The uterine fundus right after delivery of placenta is palpable at
- Midway between umbilicus and symphysis pubis
66. On which of the postpartum days can the client expect lochia serosa?
- Days 3 to 10 postpartum
67. The mechanism of Labor when the largest diameter of the head passes through the
pelvic inlet is said to be:
- Engagement
68. The _____ is the greatest determinant in the vaginal delivery of the fetus.
- Fetal position
69. Burst of energy or “nesting instinct” and fatigue may occur right before the onset of
labor. This is due to:
- An increase in epinephrine that is initiated by increase in progesterone produced by
the placenta
70. The following are conditions that leave the uterus unable to contract except
- Maternal age greater than 30 years
71. Theory of labor that states a hollow organ such as the uterus when full, will empty
- Uterine stretch theory
72. In stage 1 of labor, during the active phase, the cervix dilates?
- 1-3 cm
73. Delivery of the fetal head by applying pressure on the perineum with a towel while
controlling the speed of delivery by pressure with the other hand on the head is the:
- Schultz maneuver
74. The mother has delivered the placenta. You note that the shiny surface of the placenta
was delivered first. What delivery mechanisms is this known as ad is this the maternal
or baby’s surface of the placenta?
- Shultze mechanism, baby
75. Dashielle has an amniotomy. After this procedure, which of the following would be
an important nursing assessment?
- Document the amount of amniotic fluid that has been lost
76. Jenny reports in early labor she isn’t having much pain. You assess that her
contractions are also not strong. What position usually promotes efficient uterine
contractions in early labor?
- Lying-prone
77. Which of the following actions would alert you that a new mother is entering a
postpartal taking-hold phase
- She urges the baby to stay awake so that she can breastfeed him or her
78. You care for Joan at a week postpartum visit. What should her fundal height be at this
time?
- No longer palpable on her abdomen
79. A nurse is preparing to perform a fundal assessment on a postpartum client. The
initial nursing actions in performing this assessment is which of the following?
- Asks the mother to urinate and empty her bladder
80. A nurse is caring for a client in labor. The nurse determines that the client is
beginning in the 2nd stage of labor when which of the following assessments is noted?
- The cervix is dilated completely
81. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by
using a Doppler ultrasound device. The nurse most accurately determines that the
fetal heart sounds are heard by:
- Palpating the maternal radial pulse while listening to the fetal heart rate.
82. A nurse is monitoring a client in active labor and notes that the client is having
contractions every 3 minutes that lasts 45 seconds. The nurse notes that the fetal heart
rate between contractions is 100 BPM. Which of the following nursing actions is most
appropriate?
- Notify the physician or nurse midwife
83. A nurse is reviewing the record of a client in the labor room and notes that the nurse
midwife has documented that the fetus is at (-1) station. The nurse determines that the
fetal presenting part is:
- 1 cm above the ischial spine
84. A woman is 4cm dilated and wants to walk around the labor and delivery unit. Which
of the following criteria will help the nurse determine whether she should walk?
- The fetal position
85. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the
nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The
nurse documents these observations as signs of:
- Placental separation
86. A client who is gravid 1, para0 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:
- Below the ischial spines
87. Which observation would indicate that the placenta has separated from the uterine
wall and is ready for delivery.
- The umbilical cord shortens in length and changes in color
88. After doing Leopold’s maneuver, the nurse determines that the fetus is in ROP
position. To best auscultate the fetal heart tones, the Doppler is placed:
- Above the umbilicus at the midline
89. Which of the following factors affecting labor is associated with the passageway?
- The structure of the maternal pelvis (gynecoid versus android).
90. The physician asks the nurse the frequency of a laboring client’s contraction. The
nurse assesses the client’s contractions by timing from the beginning of one
contraction:
- To the beginning of the next contraction
91. The nurse observes the client’s amniotic fluid and decides that it appears normal,
because it is:
-Clear, almost colorless, and containing little white specks
92. The breathing technique that the mother should be instructed to use as the fetus’ head
is crowning is:
- Slow chest
93. 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:
- Support the perineum with the hand to prevent tearing and tell the client to pant
94. 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?
- Passageway, contractions, placental position and function, psychological response
95. Which measure would be least effective in preventing postpartum hemorrhage?
- Teach the woman the importance of rest and nutrition to enhance healing
96. During the first hours following delivery, the postpartum client is given IVF with
oxytocin added to them. The nurse understands the primary reason for this is:
- To promote uterine contraction
97. What is the correct order of the cardinal movements?
- Engagement, Descent, Flexion, Internal Rotation, Extension, External rotation,
Expulsion
98. It is the method of childbirth that focuses on labor and delivery as a natural event.
Laboring women are encourage to move around, if they like, and follow their body’s
urges to push, the method stresses special breathing patterns and other natural
relaxation techniques for dealing with pain.
- Lamaze or psychoprophylactic method
99. It uses sensory memory as an aid to understanding and working with the body in
preparation for childbirth. Pregnancy, labor and birth are considered continuing points
in the woman’s cycle life cycle.
- Grantly Dick-read method