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NCLEX RN Exam PRep Intrapartum Management
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NCLEX RN Exam PRep Intrapartum Management
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1 . The nurse assesses the pregnant client who comes to the triage unit anddetermines that she is at 4/50/—l and that the fetal HR is 148. What priority
information should the nurse collect before proceeding?
A. Time and amount of last meal
B. Number of weeks’ gestation
C. Who is attending the delivery
D. History of previous illnesses
ANSWER: B
A. The time and amount of last meal is important to know, but number of weeks’ gestation is more
important. This client is dilated at 4 cm and in active labor.
B. Knowing the weeks of gestation is most important because if she is in premature labor, she may
need to be given tocolytics to stop the process and to ensure adequate fetal lung maturity. If
she is full term, the labor process could continue.
C. Who will attend the delivery should be identified during admission to the labor unit, but it is not
the most important when being evaluated in triage.
D. History of previous illnesses should be collected during admission to the labor unit, but it is not
the most important when being evaluated in triage.
2. The nurse, admitting a 40-week primigravida to the labor unit, just
documented the results of a recent vaginal exam: 3/lOO/—2, RSP. How should
the oncoming shift nurse interpret this documentation?
A. The fetus is approximately 2 cm below maternal ischial spines.
B. The cervix is totally dilated and effaced, with fetal engagement.
C. The fetus is breech and posterior to the client’s pelvis.
D. The fetal lie is transverse, and the fetal attitude is flexion.
ANSWER: C
A. At —2, the fetus is 2 cm above, not below, the maternal ischial spines. Two centimeters below
the ischial spines would be recorded as +2.
B. The cervix is 3 cm, not totally dilated. Total dilation would be documented as 10 for the first
number. Also, the cervix is 100% effaced, which is total effacement (shortening and thinning
out).
C. The nurse should interpret 3/100/—2, RSP as the cervix is 3 cm dilated, 100% effaced, and the
fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the
mother’s pelvis (R), with the sacrum as the specific presenting part (S), which is a breech
position. This fetus is also posterior (P).
D. Fetal lie (relationship of long axis or spine of fetus to long axis of mother) is longitudinal, not
transverse. The documentation does not specify if the fetal attitude is flexion.
,3. The nurse is caring for the low-risk laboring client during the first stage of
labor. When should the nurse assess the FHR pattern? Select all that apply.
A. Before administering medications
B. At least every fifteen minutes
C. Alter vaginal examinations
D. During a hard contraction
E. When giving oxytocin
ANSWERS: A, C
A. The FHR may be affected by medications given to the mother. Therefore, a baseline FHR should
be determined before giving any medication to the laboring client and then assessed again after
giving the medication.
B. The FHR should be assessed every 30 minutes (not 15 minutes) during the first stage of labor if
the client is categorized as low risk. The FHR should be assessed every 15 minutes during the
second stage of labor.
C. The FHR should be assessed after each vaginal examination because the fetus could change
positions, or be stressed by the intrusion of the examiner’s fingers, or intact membranes could
have ruptured.
D. Although the FHR could be listened to during a contraction, it may be difficult due to muffling of
the sounds and maternal movement. It is most important to listen before and after the
contraction to more accurately detect FHR decelerations.
E. If the client is classified as low risk, she should not be receiving oxytocin (Pitocin) for labor
augmentation or induction.
4. After performing Leopold’s maneuvers and determining that the fetus is in
the RSA position, the nurse plans to assess the FHR. Place an X 011 the area of
the client’s abdomen where the nurse would best be able to listen to and count
the FHR.
, The right upper quadrant of the client’s abdomen is the best area to listen to and count the FHR when
the fetus is in the RSA (right sacrum anterior) position. When the fetus is in RSA position, the fetal back
faces the client’s right side. The fetal presentation is breech, and the fetal head is in the upper segment
of the client’s abdomen. The FHR is heard most clearly through the fetal back. This is designated as the
area of maximal intensity or loudness, providing clarity of fetal heart sounds.
5. The laboring client in the first stage of labor is talking and laughing with her
husband. The nurse should conclude that the client is probably in what phase?
A. Transition
B. Active
C. Active pushing
D. Latent
ANSWER: D
A. During the transition phase (8—10 cm), the client is usually more restless, irritable, and more
likely to lose control.
B. During the active phase (4—7 cm), the client may become more anxious and fatigued and needs
to concentrate on breathing techniques to cope with the increasingly stronger contractions.
C. The client who is actively pushing is focusing on how effective she is in the descent of the fetus
and concentrating on how she is coping with contractions. She is usually not expressing
happiness or laughter, and is not talkative.
D. During the latent phase (1—3 cm), the client is usually happy and talkative.
6. The nurse just administered butorphanol tartrate as prescribed to the
client in active labor. Following administration of butorphanol tartrate, what
is the nurse’s most important action to help prevent side effects?
A. Assess the client’s bladder for distention
B. Place the client on seizure precautions
C. Assess the client’s body for itchy rash
D. Evaluate her vital signs and pulse oximetry
ANSWER: D
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