perineum indicate the birth of the baby is

imminent?
BSN 2_ P2 WEEK 1 POST TEST
NUR 194_LEC_Care of Mother and Child A. Increase in meconium-stained fluid and
Adolescent (Well Client) retracting perineum
—
--------------- B. Retracting perineum and anus with an
GENERAL INSTRUCTIONS: increase of bloody show
Shade only those that apply to each
question on your answer sheet. C. Rapid and intense contractions
Read the question carefully and choose the
best answer. D. Bulging perineum and rectum with an
STRICTLY NO ERASURES. increase in bloody show
—
--------------- 4. During stage 3 of labor, you note a gush of
blood and that the uterus changes shape from an
1.J.A. makes the following statements. Which oval shape to globular shape. This indicates?
one would the nurse rate as the safest practice?
12.6 A. Postpartum hemorrhage
B. Imminent delivery of the baby
a. “My brother takes medicine for heartburn; if C. Signs of placental separation
I think of it, I’ll borrow his.” D. Answers B and C
b. “I’m going to get a measles shot; I don’t
want measles while I’m pregnant.” 5. The nurse has received report regarding her
c. “There are so many medicines for patient in labor. The woman's last vaginal
headache; I’ll ask my doctor what to take.” examination was recorded as 3 cm, 30%, and ?2-
d. “I know all over-the-counter medicine is 2. The nurse's interpretation of this assessment is
safe; that’s why it’s over the counter.” that:

RATIONALE : The nurse should teach that a. The cervix is effaced 3 cm, it is dilated 30%,
when pregnant, persons should check with their and the presenting part is 2 cm above the ischial
healthcare provider before taking medication. spines.
All over-the-counter medicines are not safe; b. The cervix is 3 cm dilated, it is effaced 30%,
measles and the presenting part is 2 cm above the ischial
vaccine contains a live virus and so it is spines.
contraindicated during pregnancy. c. The cervix is effaced 3 cm, it is dilated 30%,
2. You're performing a routine assessment on a and the presenting part is 2 cm below the ischial
mother post-delivery. The uterus is soft and spines.
displaced to the left of the umbilicus. What is d. The cervix is dilated 3 cm, it is effaced 30%,
your next nursing action? and the presenting part is 2 cm below the ischial
spines.
A. Perform fundal massage
B. Continue to monitor the mother. This is a normal Ratio: (The correct description of the vaginal
finding post-delivery. examination for this woman in labor is the
C. Notify the physician. cervix is 3 cm dilated, it is effaced 30%, and the
D. Administer PRN dose of Pitocin as ordered presenting part is 2 cm above the ischial spines.
by the physician. The sterile vaginal examination is recorded as
centimeters of cervical dilation, percentage of
3. Your laboring patient has transitioned to stage cervical dilation, and the
2 of labor. What changes in the
relationship of the presenting part to the ischial
spines (either above or below).) 9. With regard to the turns and other adjustments
of the fetus during the birth process, known as
6. The nurse would expect which maternal the mechanism of labor, nurses should be aware
cardiovascular finding during labor? that:
a. Increased cardiac output a. The seven critical movements must progress
b. Decreased pulse rate in a more or less orderly sequence.
c. Decreased white blood cell (WBC) count b. Asynclitism sometimes is achieved by
d. Decreased blood pressure means of the Leopold maneuver.
c. The effects of the forces determining descent
RATIO: are modified by the shape of the woman's pelvis
(During each contraction, 400 mL of blood is and the size of the fetal head.
emptied from the uterus into the maternal d. At birth the baby is said to achieve
vascular system. This increases cardiac output "restitution" (i.e., a return to the C-shape of the
by about 51% above baseline pregnancy values womb).
at term. The heart rate increases slightly during
labor. The WBC count can increase during RATIO:
labor. (The size of the maternal pelvis and the
ability of the fetal head to mold also affect
7. The factors that affect the process of labor and
birth, known commonly as the five Ps, include the process. The seven identifiable
all except: movements of the mechanism of labor occur
in combinations simultaneously, not in
a. Passenger. precise sequences. Asynclitism is the
b. Powers. deflection of the baby's head; the Leopold
c. Passageway. maneuver is a means of judging descent by
d. Pressure. palpating the mother's abdomen. Restitution
is the rotation of the baby's head after the
RATIO: infant is born.)
(The five Ps are passenger (fetus and placenta),
passageway (birth canal), powers (contractions),
10.As relates to fetal positioning during
position of the mother, and psychologic
response.) labor, nurses should be aware that:

8. Which description of the four stages of labor a. Position is a measure of the degree of
is correct for both definition and duration? descent of the presenting part of the fetus
through the birth canal.
a. First stage: onset of regular uterine b. Birth is imminent when the presenting
contractions to full dilation; less than 1 hour to part is at +4 to +5 cm below the spine.
20 hours c. The largest transverse diameter of the
b. Second stage: full effacement to 4 to 5 cm; presenting part is the
visible presenting part; 1 to 2 hours suboccipitobregmatic diameter.
c. Third state: active pushing to birth; 20
d. Engagement is the term used to describe
minutes (multiparous women), 50 minutes (first-
timer) the beginning of labor.
d. Fourth stage: delivery of the placenta to
recovery; 30 minutes to 1 hour
11. Which statement is the best rationale for expulsion of the fetus. Effacement generally
assessing maternal vital signs between
is well ahead of dilation in first-timers; they
contractions?
are closer together in subsequent
a. During a contraction, assessing fetal heart pregnancies. Scarring of the cervix may
rates is the priority. slow dilation. Pushing is more effective and
b. Maternal circulating blood volume less fatiguing when the woman begins to
increases temporarily during contractions. push only after she has the urge to do so.
c. Maternal blood flow to the heart is
reduced during contractions. 13. In order to care for obstetric patients
d. Vital signs taken during contractions are not adequately, the nurse understands that labor
accurate. contractions facilitate cervical dilation by:
RATIO: (During uterine contractions, blood
a. Contracting the lower uterine
flow to the placenta temporarily stops, segment.
causing a relative increase in the mother's b. Enlarging the internal size of the
blood volume, which in turn temporarily uterus.
increases blood pressure and slows pulse. It c. Promoting blood flow to the cervix.
is important to monitor fetal response to d. Pulling the cervix over the fetus and
contractions; however, this question is amniotic sac.
concerned with the maternal vital signs.
Maternal blood flow is increased during a RATIO:Effective uterine contractions pull
contraction. Vital signs are altered by the cervix upward at the same time that the
contractions but are considered accurate for fetus and amniotic sac are pushed
that period of time.) downward. The contractions are stronger at
12. In relation to primary and secondary powers,
the fundus. The internal size becomes
the maternity nurse comprehends that: smaller with the contractions; this helps to
push the fetus down. Blood flow decreases
a. Primary powers are responsible for to the uterus during a contraction.
effacement and dilation of the cervix.
b. Effacement generally is well ahead of 14. While providing care to a patient in
dilation in women giving birth for the first time; active labor, the nurse should instruct the
they are closer together in subsequent woman that:
pregnancies.
c. Scarring of the cervix caused by a previous a. The supine position commonly used in
infection or surgery may make the delivery a bit the United States increases blood flow.
more painful, but it should not slow or inhibit b. The "all fours" position, on her hands and
dilation.
knees, is hard on her back.
d. Pushing in the second stage of labor is more c. Frequent changes in position will help
effective if the woman can breathe deeply and
control some of her involuntary needs to push,
relieve her fatigue and increase her comfort.
as the nurse directs.

RATIO:The primary powers are responsible

for dilation and effacement; secondary
powers are concerned with
d. In a sitting or squatting position, her d. Sequence of labor mechanisms.
abdominal muscles will have to work harder.
RATIO:(In a first-time pregnancy, descent is
RATIO:Frequent position changes relieve usually slow but steady; in subsequent
fatigue, increase comfort, and improve pregnancies, descent is more rapid, resulting
circulation. Blood flow can be compromised in a shorter duration of labor. Cervical
in the supine position; any upright position dilation is the same for all labors. Level of
benefits cardiac output. The "all fours" pain is individual to the woman, not to the
position is used to relieve backache in number of labors she has experienced. The
certain situations. In a sitting or squatting sequence of labor mechanisms is the same
position, the abdominal muscles work in with all labors.)
greater harmony with uterine contractions.
17. A primigravida at 39 weeks of gestation
15. To teach patients about the process of is observed for 2 hours in the intrapartum
labor adequately, the nurse knows that unit. The fetal heart rate has been normal.
which event is the best indicator of true Contractions are 5 to 9 minutes apart, 20 to
labor? 30 seconds in duration, and of mild
intensity. Cervical dilation is 1 to 2 cm and
a. Bloody show uneffaced (unchanged from admission).
b. Cervical dilation and effacement Membranes are intact. The nurse should
c. Fetal descent into the pelvic inlet expect the woman to be:
d. Uterine contractions every 7 minutes
a. Admitted and prepared for a cesarean
RATIO: birth.
(As the cervix begins to soften, dilate, and b. Admitted for extended observation.
efface, expulsion of the mucous plug that c. Discharged home with a sedative.
sealed the cervix during pregnancy occurs. d. Discharged home to await the
This causes rupture of small cervical onset of true labor.
capillaries. Cervical dilation and effacement
do not occur with false labor. Lightening is RATIO:This situation describes a woman
the descent of the fetus toward the pelvic with normal assessments who is probably in
inlet before labor. Bladder distention occurs false labor and will probably not deliver
when the bladder is not emptied frequently. rapidly once true labor begins. These are all
It may slow down the descent of the fetus indications of false labor without fetal
during labor.) distress. There is no indication that further
assessment or cesarean birth is indicated.
16. The primary difference between the The patient will likely be discharged;
labor of a nullipara and that of a multipara is however, there is no indication that a
the: sedative is needed.)
a. Amount of cervical dilation. 18. Which nursing assessment indicates that
b. Total duration of labor. a woman who is in second-stage labor is
c. Level of pain experienced. almost ready to give birth?
 C maternal effects are only seen with
a. The fetal head is felt at 0 station viral teratogens
during vaginal examination. D genetic factors are not present
b. Bloody mucus discharge increases. with viral teratogens
c. The vulva bulges and encircles the
fetal head. 23. A fetus is particularly susceptible to
d. The membranes rupture during a rubella infection when maternal infection
contraction. occurs during what stage of pregnancy?
A 1st trimester
19. Clinical features such as B 2nd trimester
hepatosplenomegaly, skin and mucosal C 3rd trimester
lesions, and a saddle-shaped nose are D susceptibility unknown
associated with what congenital infection?
ratio:During the first 3 months, organ
a.congenital rubella development occurs. virus interfere with
b.congenital CMV development of heart, brain, eyes and ears
c.congenital syphilis
d.Congenital HIV 24. The nurse should teach a pregnant
woman that which substances are
20. What antibody, produced by the fetus, teratogens? (Select all that apply)
can be detected in the cord blood of an
infant infected with the rubella virus? I. Cigarette smoke
a.IgA II. Isotretinoin (Retin A)
b.IgD III. Vitamin C
c.IgG IV. Salicylic acid
d.IgM V. Rubella

21. Congenital rubella is completely a. I,II,V c.II,III,IV,V

preventable by b. I,II,III d.III,IV,V

A isolation 25. At what time during gestation is a fetus

B vaccination most susceptible to congenital rubella
C having a superb immune system syndrome?
D. hand washing
a. Week 20-30
22. A distinguishing factor between viral b.Week 30-40
teratogens (rubella) and other teratogens c.Week 12-20
(drugs, radiation) would be that d. The first 12 weeks after conception
A only viral teratogens cause retarded fetal
growth Rationale : Infants who are exposed to
B fetal death is only a possibility with rubella during weeks 0-12 of gestation have
other teratogens, not viral a 51% chance of developing congenital
rubella syndrome. If the fetus is exposed to
the virus between 12 and
26 weeks, the incidence of defects
drops to 23%. Congenital rubella syndrome 28. Which situation is an indication for an
is rare in infants whose mothers were oxytocin infusion?
initially exposed to the virus after 26 weeks
of gestation. Interestingly, the fetus is more A. Hypertonic uterus
likely to have birth defects if the mother B. Pelvic inflammatory disease
contracted rubella before conception - C. Induction of labor at full-term
infants whose mothers contracted the virus D. Cervical stenosis in a client who is in
0-4 weeks before conception have as much labor
as 43% incidence of congenital rubella
syndrome, due to it's long incubation period. 29. A client is admitted for induction of
labor. An intravenous infusion of oxytocin is
26. Which of the following is a risk factor started. When the client's contractions begin
for development of toxoplasmosis in they are 1.5 to 2 minutes in duration. While
pregnancy? the nurse is in the room, one contraction
lasts 3 minutes. What should the nurse do
a.Undercooked meat first?
b.Contaminated water
c.All of these A. Give oxygen by nasal cannula.
d.Exposure to cat feces (often via a litter B. Turn off the oxytocin infusion.
box) C. Reposition the monitoring belts.
D. Place a call light next to the client.
27. Congenital disorders refer to conditions
that are present at birth. These disorders may 30. Which statement regarding a
be inherited and caused by environmental teratogenic drug is incorrect?
factors or maternal malnutrition. Toxic
exposures have the greatest effect on A. Teratogenic drugs cause
development between 15 and 60 days of characteristic malformation.
gestation. For the nurse to be able to conduct B. Teratogenic drugs act during all
a complete assessment of the newly periods of gestation.
pregnant client, she should understand the C. An increase in the dosage of
significance of exposure to known human teratogenic drugs increases the incidence of
teratogens. These include(Select all that malformation.
apply): D. An increase in the duration of exposure
to teratogenic drugs increases the incidence
I. Infections. of malformation.
II. Radiation.
III. Maternal conditions.
IV. Drugs.
V. Chemicals.

a. I,II,III,IV b. All of the above

C. II,III,IV,V d. II,III,V
 e. “I understand. You don’t want to
come to the hospital before you are
in labor.”
BSN 2_ P2 WEEK 2 POST TEST
NUR 194_LEC_Care of Mother and Child 4. , While performing Leopold’s maneuvers on
Adolescent (Well Client) a woman in labor the nurse palpates a hard
—-------------------------------------------------------- round mass in the fundal area, a flat surface
--------------- on the left side, small objects on the right
GENERAL INSTRUCTIONS: side, and a soft round mass just above the
Shade only those that apply to each symphysis. Which of the following is a
question on your answer sheet. reasonable conclusion by the nurse?
Read the question carefully and choose the a. The fetal position is transverse
best answer. b. The fetal presentation is vertex
STRICTLY NO ERASURES. c. The fetal lie is vertical
d. The fetal attitude is flexed
—--------------------------------------------------------
--------------- 5. The nurse is assessing the fetal station
during a vaginal examination. Which of the
1. When assessing the psychological following structures should the nurse
adjustment of an 8-week gravida, which of palpate?
the following would the nurse expect to see a. Sacral promontory
signs of? b. Ischial spines
a. Ambivalence c. Cervix
b. Depression d. Symphysis pubis
c. Anxiety
d. Ecstasy 6. The labor and delivery nurse performs
Leopold’s maneuvers. A soft round mass is
2. A 36 week gestation gravid client is felt in the fundal region. A flat object is
complaining of dyspnea when lying flat. noted on the left and small objects are noted
Which of the following is the likely clinical on the right of the uterus. A hard round mass
reason for this complaint? is noted above the symphysis. Which of the
a. Maternal hypertension following positions is consistent with these
b. Fundal height findings?
c. Hydramnios a. Left occipital anterior (LOA)
d. Congestive heart failure b. Left sacral posterior (LSP)
c. Right mentum anterior (RMA)
3. A client in her third trimester is concerned d. Right sacral posterior (RSP)
that she will not know the difference
between labor contractions and normal 7. During a vaginal examination, the nurse
aches and pains of pregnancy. How should palpates fetal buttocks that are facing the left
the nurse respond? posterior and are 1 cm above the ischial
a. “Don't worry. You’ll know the spines. Which of the following is consistent
difference when the contractions with this assessment?
start.” a. LOA -1 station
b. “The contractions may feel b. LSP -1 station
just like a backache, but they c. LMP +1 station
will come and go.” d. LSA +1 station
c. “Contractions are a lot worse than
your pregnancy aches and pains.” 8. The nurse enters a laboring client’s room.
d. “I understand. You don’t want to The client is complaining of intense back
come to the hospital before you are pain with each contraction. The nurse
in labor.” concludes that the fetus is likely in which of
the following positions?
a. Mentum anterior
 b. Sacrum posterior d. “The baby is almost
c. Occiput posterior crowning.=
d. Scapula anterior
14. A woman who is in active labor is told by
9. When performing Leopold’s maneuvers, the her obstetrician, “Your baby is in the flexed
nurse notes that the fetus is in the left attitude,” When she asks the nurse what that
occiput anterior position. Which is the best means, what should the nurse say?
position for the nurse to place a fetoscope to a. The baby is in the breech position
hear the fetal heartbeat? b. The baby is in horizontal lie
a. Left upper quadrant c. The baby’s presenting part is
b. Right upper quadrant engaged,
c. Left lower quadrant d. The baby’s chin is resting on
d. Right lower quadrant its chest
10. On examination, it is noted that a full- 15. An ultrasound report states, “The fetal head
term primipara in active labor is right has entered the pelvic inlet.” What does the
occipitoanterior (ROA), 7 cm dilated, and nurse interpret this statement to mean?
3+ station. Which of the following should a. The fetus has become engaged
the nurse report to the physician? b. The fetal head has entered the
a. Descent is progressing well true pelvis
b. Fetal head is not yet engaged c. The fetal lie is horizontal
c. Vaginal delivery is imminent d. The fetus is in an extended attitude
d. External rotation is complete
16. Which of the following pictures depicts a
11. A nurse has just performed a vaginal fetus in the ROP position?
examination on a client in labor. The nurse
palpates the baby’s buttocks as facing the
mother’s right side. Where should the nurse
place the external fetal monitor electrode?
a. Left upper quadrant (LUQ)
b. Left lower quadrant (LLQ)
c. Right upper quadrant (RUQ)
d. Right lower quadrant (RLQ)

12. A nurse determines that a client is carrying a

fetus in the vertical lie. The nurse’s a. 1
judgment should be questioned if the fetal b. 2
presenting part is which of the following? c. 3
a. Sacrum d. 4
b. Occiput
c. Mentum
d. Scapula

13. The nurse sees the fetal head through the

vaginal introitus when a woman pushes. The
nurse, interpreting this finding, tells the
client, “You are pushing very well.” In
addition, the nurse could also state which of
the following?
a. “The baby’s head is engaged.”
b. “The baby is floating.” 17. Which of the following pictures depicts a
c. “The baby is at the ischial spines.” fetus in the LSA position?
 a. I, II, III, IV
b. II, III, IV, V
c. I, II, IV, V
d. I, III, IV, V

20. A client in labor is talkative and happy. How

many centimeters dilated would a maternity
a. 1 nurse suspect that the client is at this time?
b. 2 a. 2 cm
c. 3 b. 4 cm
d. 4 c. 8 cm
d. 10 cm
18. Which of the following pictures depicts a
fetus in the frank breech position? 21. A nurse is assisting an anesthesiologist who
is inserting an epidural catheter. Which of
the following positions should the nurse
assist the woman into?
a. Fetal position
b. Lithotomy position
c. Trendelenburg position
d. Lateral recumbent position

22. What type of pelvic is this?

a. 1
b. 2
c. 3
d. 4

19. A pregnant woman is discussing positioning

and the use of leg stirrups for delivery with
a labor nurse. Which of the following client
responses indicates that the client
understood the information? Select all that
apply.
Ⅰ When the client states, “I am glad a. Gynecoid
that deliveries can take place in a b. Android
variety of places, including a c. Anthropoid
jacuzzi bathtub.” d. Platypelloid
II When the client says, “I heard that
for doctors to deliver babies safely,
it is essential to have the mother’s
legs up in stirrups.”
III When the client says, “I understand
that if the fetus needs to turn during
labor, I may end up delivering the
baby on my hands and knees.”
IV When the client says, “During
difficult deliveries it is sometimes
necessary to put a
woman’s legs up in stirrups.”
V When the client states, “I heard that 23. What type of pelvic is this?
midwives often deliver their
patients either in the side-lying or
squatting position.”
 26. What is the primary psychological component
experienced by a woman during the first stage of
labor?

A. Anxiety and fear

B. Euphoria and excitement
C. Confusion and indecision
D. Apathy and detachment

concerns about the pain and potential complications.

27. Which psychological response is often associated

a. Gynecoid with the transition phase of labor?
b. Android
c. Anthropoid A. Calm and relaxation
d. Platypelloid B. Overwhelming joy
C. Irritability and impatience
24. What type of pelvic is this? D. Indifference and detachment

RATIO: irritability and impatience are often

observed during the transition phase of labor. The
intense contractions and physical discomfort can lead
to heightened emotions, including irritability due to
the challenging nature of this phase.

28. How can the presence of a supportive birth

partner positively influence the psychological
component of labor?

A. Increase feelings of isolation

B. Amplify feelings of fear
a. Gynecoid C. Enhance feelings of control and safety
b. Android D. Heighten feelings of medical intervention
c. Anthropoid
d. Platypelloid RATIO: The presence of a supportive birth partner
can enhance feelings of control and safety. This
25. What type of pelvic is this? support can help reduce anxiety, promote a sense of
comfort, and provide reassurance during the labor
process.

29. Which psychological factor is most likely to

contribute to the woman's ability to cope with labor
pain?

A. High levels of stress

B. Lack of social support
C.Positive mindset and relaxation techniques
D.History of past traumatic experiences

RATIO: A positive mindset and relaxation

a. Gynecoid techniques are likely to contribute to a woman's
b. Android ability to cope with labor pain. These factors can help
c. Anthropoid her manage stress and anxiety, which in
d. Platypelloid
turn can improve her pain perception during labor.

30. Which psychological factor might contribute to

prolonged labor or hinder the progress of labor?

A. Supportive medical staff

B. A sense of control band empowerment
C. High levels of anxiety and stress
D. Adequate pain management

RATIO: High levels of anxiety and stress might

contribute to a prolonged labor or hinder its progress.
Stress can lead to the release of stress hormones,
which may interfere with the natural hormonal
processes necessary for labor progression.
 bends forward onto the chest, causing the
smallest anteroposterior diameter to present
to the birth canal. What part of the
mechanism of labor does this refer to?
BSN 2_ P2 WEEK 3 POST TEST a. Engagement
NUR 194_LEC_Care of Mother and Child b. Descent
Adolescent (Well Client) c. Extension
— d. Flexion
---------------
GENERAL INSTRUCTIONS: 5. Nurse Bryent is assessing the fetal station
Shade only those that apply to each during a vaginal examination. Which of the
question on your answer sheet. following structures should the nurse
Read the question carefully and choose the palpate?
a. Sacral promontory
best answer.
b. Ischial spine
STRICTLY NO ERASURES. c. Cervix
— d. Symphysis Pubis
---------------
6. Nurse Bryent is caring for a laboring woman
1. While nurse Bryent is performing Leopold’s who is in transition. Which of the following
maneuvers on a woman in labor, the nurse signs/symptoms would indicate that the
palpates a hard round mass in the fundal woman is progressing into the second stage
area, a flat surface on the left side, small of labor? Select all that apply.
objects on the right side and a soft round a. Bulging perineum
mass just above the symphysis. Which of the b. Increased bloody show
following is a reasonable conclusion by the c. Spontaneous rupture of the
nurse? membranes
a. The fetal position is transverse d. Uncontrollable urge to push
b. The fetal presentation is vertex
c. The fetal lie is vertical 7. During descent, the biparietal diameter of
d. The fetal attitude is flexed the skull was aligned to fit through the
anteroposterior diameter of the mother’s
2. This refers to the settling of the presenting pelvis. What part of the mechanism of labor
part of a fetus far enough into the pelvis that does this refer to?
it rests at the level of the ischial spine. What a. Internal rotation
part of the Cardinal movement of labor does b. Extension
this mean? c. External rotation
a. Engagement d. Expulsion
b. Descent
c. Extension 8. As the occiput of the fetal head is born, the
d. Flexion back of the neck stops beneath the pubic
arch and acts as a pivot for the rest of the
3. This refers to the downward movement of head. What part of the mechanism of labor
the biparietal diameter of the fetal head does this refer to?
within the pelvic inlet. What part of the a. Internal rotation
Cardinal movement of labor does this mean? b. Extension
a. Engagement c. External rotation
b. Descent d. Expulsion
c. Extension
d. Flexion 9. Almost immediately after the head of the
infant is born, the head rotates a final time
4. As descent is completed and the fetal head back to the diagonal or transverse position
touches the pelvic floor, the head of the early part of labor. What
 part of the mechanism of labor does this 14. The mother’s Cervix dilation is 5 cm with a
refer to? contraction intensity of moderate, frequency
a. Internal rotation of the contraction is 4 minutes and a
b. Extension duration of 50 seconds. What part in the first
c. External rotation stage of labor is this?
d. Expulsion a. Latent
b. Active
10. Once the shoulders are born, the rest of the c. Transition
baby is born easily and smoothly because of d. None of the above
its smaller size. What part of the Cardinal
Movements of labor does this refer to? 15. The mother’s Cervix dilation is 9 cm with a
a. Internal rotation contraction intensity of strong, frequency of
b. Extension the contraction is 2 minutes and a duration
c. External rotation of 80 seconds. What part in the first stage of
d. Expulsion labor is this?
a. Latent
11. On examination it is noted that a full - term b. Active
primipara in active labor is right c. Transition
occipitoanterior (ROA), 7 cm dilated, and d. None of the above
+3 station. Which of the following should
the nurse report to the physician? 16. The childbirth educator is teaching a class of
a. Descent is progressing well pregnant couples the breathing technique
b. Fetal head is not yet engaged that is most appropriate during the second
c. Vaginal delivery is imminent stage of labor. Which of the following
d. External rotation is complete techniques did the nurse teach the women to
do?
12. One hour ago, a multipara was examined a. Alternately pant and blow
with the following results: 8 cm, 50% b. Take rhythmic, shallow breaths
effaced, and +1 station. She is now pushing c. Push down with an open
with contractions and the fetal head is seen glottis
at the vaginal introitus. The nurse concludes d. Do slow chest breathing
that the client is now:
a. 9 cm dilated, 70% effaced and 17. A nurse is teaching a class of pregnant
+2 station couples the most therapeutic breathing
b. 9 cm dilated, 80% effaced and technique for the latent phase of labor.
+3 station Which of the following techniques did the
c. 10 cm dilated, 90% effaced, and nurse teach?
+4 station a. Alternately panting and blowing
d. 10 cm dilated, 100% effaced, b. Rapid, deep breathing
and +5 station c. Grunting and pushing with
contractions
13. The mother’s cervix dilation is 1 cm with d. Slow chest breathing
contraction intensity that is mild, the 18. In addition to breathing with contractions,
contraction’s frequency is every 6 minutes which of the following actions can help a
with a duration of 30 seconds. What part in woman in the first stage of labor to work
the First stage of labor is this? with her pain?
a. Latent a. Lying in the lithotomy position
b. Active b. Performing effleurage
c. Transition c. Practicing Kegel exercises
d. None of the above d. Pushing with each contraction
19. Upon examination, a nurse notes that a
woman is 10 cm dilated, 100% effaced, and
-3 station. Which of the following actions
should the nurse perform during the next
contraction?
a. Encourage the woman to push
 b. Provide firm fundal pressure following is included in the Cardinal
c. Move the client into a squat Movement? Select all that apply
d. Monitor for signs of rectal a. Descent
pressure b. Expulsion
c. Extension
20. Nurse Bryent is assessing a client who d. External rotation
states. “I think I’m in labor.” Which of the
following findings would positively confirm 24. The nurse sees the fetal head through the
the client’s belief? vaginal introitus when a woman pushes. The
a. She is contracting q 5 min x 60 sec nurse, interpreting this finding, tells the
b. Her cervix has dilated from 2 client, “You are pushing very well.” In
to 4 cm addition, the nurse could also state which of
c. Her membranes have rupture the following?
d. The fetal head is engaged a. “The baby’s head is engaged.”
b. “The baby is floating.”
21. A woman, 40 weeks’ gestation, calls the c. “The baby is at the ischial spines.”
labor unit to see whether or not she should d. “The baby is almost
go to the hospital to be evaluated. Which of crowning.”
the following statements by the woman
indicates that she is probably in labor and 25. A midwife advises a mother that her
should proceed to the hospital? obstetric conjugate is of average size. How
a. “The contractions are 5 to 20 should the nurse interpret that Information
minutes apart.” for the mother?
b. “I saw a pink discharge on the a. The anterior to posterior
toilet tissue when I went to the diameter of the pelvis will
bathroom” accommodate a fetus with an
c. “I have had cramping for the past 3 average-sized head
or 4 hours” b. The fetal head is flexed so that it is
d. “The contractions are about a of average diameter
minute long and I am unable c. The mother’s cervix is of average
to talk through them” dilation for the start of labor
d. The distance between the mother’s
22. A nurse describes a client’s contraction physiological retraction ring and
pattern as frequency every 3 min and the fetal head is of average
duration 60 sec. Which of the following dimensions.
responses corresponds to this description? 26. Which of the following is a maternal danger
a. Contractions lasting 60 seconds sign that requires immediate medical
followed by a 1 minute rest period attention?
b. Contractions lasting 120
seconds followed by a 2-minute A) Mild backache
rest period. B) Frequent urination
c. Contractions lasting 2 minutes C) Braxton Hicks contractions
followed by a 60-second rest D) Vaginal bleeding
period.
d. Contractions lasting 1 minute Rationale: Vaginal bleeding during
followed by a 120-second rest pregnancy can indicate serious conditions
period. such as placental abruption or miscarriage.
Immediate medical attention is needed to
23. A nurse is educating a pregnant woman assess and manage the situation.
regarding the moves a fetus makes during
the birthing process. Which of the 27. Which maternal danger sign is associated
with severe, persistent
headache, visual disturbances, and upper C) Hyperemesis gravidarum
abdominal pain? D) Excessive exercise
A) Round ligament pain
B) Morning sickness
C) Preeclampsia Rationale: Hyperemesis gravidarum is a
D) Braxton Hicks contractions severe form of morning sickness
characterized by persistent vomiting, weight
Rationale: Severe headache, visual loss, and dehydration. It requires medical
disturbances, and upper abdominal pain are intervention to manage the symptoms and
classic symptoms of preeclampsia. This prevent co
condition requires medical attention to
prevent complications for both the mother
and the baby.

28. A pregnant woman experiences sudden

gush of clear fluid from the vagina before 37
weeks of gestation. What could this
indicate?

A) Increased amniotic fluid

B) Normal vaginal discharge
C) Premature rupture of membranes
D) Urinary incontinence

Rationale: A sudden gush of clear fluid from

the vagina before 37 weeks could indicate
premature rupture of membranes, which
increases the risk of infection and preterm
labor. Prompt medical evaluation is
necessary.

29. If a pregnant woman complains of

decreased fetal movement, what should be
the healthcare provider's response?

A) Advise bed rest

B) Reassure her that it's normal
C) Suggest increasing caffeine intake
D) Perform a thorough evaluation,
including fetal monitoring

Rationale: Decreased fetal movement could

indicate fetal distress. A thorough
evaluation, including fetal monitoring, helps
assess the baby's well-being and decide the
appropriate course of action.

30. A pregnant woman presents with

persistent vomiting, weight loss, and
dehydration. What could this be a sign of?

A) Normal morning sickness

B) Gestational diabetes