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RNC-MNN practice questions

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Question 1Antepartum Care

A client at 10 weeks' gestation reports morning nausea that occurs mostly before breakfast. Which instruction should the nurse give first?

  1. Skip breakfast until the nausea passes
  2. Drink a large glass of water immediately on waking
  3. Eat a few dry crackers before getting out of bed Correct answer.
  4. Take an antiemetic before each meal

Explanation

Small, dry, bland foods eaten before rising help reduce nausea related to an empty stomach and postural changes. Dietary measures are first-line before medications in uncomplicated nausea of pregnancy.

Question 2Antepartum Care

Which finding is an expected physiologic change of pregnancy rather than a sign of illness?

  1. Blood pressure falling slightly in the second trimester Correct answer.
  2. Fasting blood glucose rising above 126 mg/dL
  3. Hemoglobin rising above prepregnancy levels
  4. Urine protein of 2+ on dipstick

Explanation

Peripheral vasodilation and the placental circuit lower systemic vascular resistance, so blood pressure typically dips in mid-pregnancy before returning toward baseline near term. The other findings require evaluation.

Question 3Antepartum Care

A client at 12 weeks' gestation asks when her pregnancy will be dated by fundal height. What is the best response?

  1. Fundal height is accurate from 8 weeks onward
  2. Fundal height is never used before 32 weeks
  3. Fundal height replaces ultrasound dating at 16 weeks
  4. Fundal height becomes a useful gauge at about 20 weeks Correct answer.

Explanation

The uterus becomes palpable abdominally near 12 weeks, but fundal height measured in centimeters is reliable for dating from roughly 20 weeks (at the umbilicus) to 36 weeks. Earlier dating relies on ultrasound and last menstrual period.

Question 4Antepartum Care

At what point in pregnancy does the fundus typically reach the level of the umbilicus?

  1. About 28 weeks
  2. About 12 weeks
  3. About 34 weeks
  4. About 20 weeks Correct answer.

Explanation

The uterine fundus is palpable at the symphysis near 12 weeks and reaches the umbilicus at approximately 20 weeks' gestation. This landmark is a standard part of dating and growth assessment.

Question 5Antepartum Care

A client reports that her nausea of pregnancy has stopped abruptly at 9 weeks and she feels no breast tenderness. What is the priority nursing action?

  1. Advise her to increase oral fluids and return in 4 weeks
  2. Notify the provider for evaluation of fetal viability Correct answer.
  3. Reassure her that symptoms resolve early in some pregnancies
  4. Schedule her routine anatomy ultrasound at 20 weeks

Explanation

Loss of pregnancy symptoms before the expected time can signal embryonic demise and should be evaluated promptly. Ultrasound and serial hCG assessment can confirm viability.

Question 6Antepartum Care

A client at 16 weeks' gestation has a fundal height of 22 cm. Which interpretation is most appropriate?

  1. The measurement is normal for this gestational age
  2. The measurement should be repeated after 24 weeks
  3. The measurement exceeds expected size and needs evaluation Correct answer.
  4. The measurement indicates intrauterine growth restriction

Explanation

Between 20 and 36 weeks fundal height in centimeters approximates gestational age in weeks within about 2 to 3 cm. A 6-cm discrepancy above expectation warrants evaluation for multifetal gestation, polyhydramnios, or incorrect dating.

Question 7Antepartum Care

A client at 28 weeks' gestation has a one-hour 50-g glucose challenge result of 156 mg/dL. What is the next appropriate step?

  1. Diagnose gestational diabetes and begin insulin
  2. Restrict carbohydrates and recheck in 3 months
  3. Perform a 3-hour 100-g oral glucose tolerance test Correct answer.
  4. Repeat the 50-g challenge in 4 weeks

Explanation

A screening value above the usual threshold (commonly 130 to 140 mg/dL, lab-dependent) requires diagnostic testing with a 3-hour 100-g oral glucose tolerance test. Diagnosis is not made from the screening test alone.

Question 8Antepartum Care

Which client has a risk factor that most strongly warrants early screening for gestational diabetes at the first prenatal visit?

  1. A 30-year-old who exercises five days a week
  2. A 28-year-old with one prior uncomplicated term birth
  3. A 34-year-old with a body mass index of 33 Correct answer.
  4. A 22-year-old with a body mass index of 22

Explanation

Obesity and age over 25 are recognized risk factors that support early glucose screening in pregnancy. Average-risk clients are screened at 24 to 28 weeks.

Question 9Antepartum Care

A client at 33 weeks' gestation has a blood pressure of 148/96 mm Hg on two occasions and 2+ proteinuria. Which condition should the nurse suspect?

  1. Gestational hypertension
  2. Chronic hypertension
  3. Normal pregnancy-induced vasodilation
  4. Preeclampsia without severe features Correct answer.

Explanation

New hypertension after 20 weeks plus proteinuria meets criteria for preeclampsia. Severe features would include pressures of 160/110 or higher, low platelets, elevated liver enzymes, or symptoms such as headache or visual change.

Question 10Antepartum Care

A client at 30 weeks' gestation with preeclampsia reports a severe headache and blurred vision. Which action is the priority?

  1. Give acetaminophen and reassess in one hour
  2. Encourage rest in a dark room and recheck blood pressure tomorrow
  3. Notify the provider immediately for urgent evaluation Correct answer.
  4. Document the symptoms as expected in late pregnancy

Explanation

Headache and visual changes are warning signs of severe preeclampsia with possible progression to eclampsia. Urgent provider notification allows for magnesium sulfate and antihypertensive therapy.

Question 11Antepartum Care

A client at 18 weeks' gestation reports a sudden gush of clear fluid from the vagina. Which assessment should the nurse perform first?

  1. Sterile speculum examination to visualize pooling Correct answer.
  2. Urine culture and sensitivity
  3. Abdominal palpation for fetal position
  4. Vaginal douching to clear the fluid

Explanation

Sterile speculum examination can confirm pooling of amniotic fluid in the vaginal vault and allows collection for ferning or pH testing. Digital examination is avoided because it can introduce infection.

Question 12Antepartum Care

A client at 26 weeks' gestation with ruptured membranes is being managed expectantly. Which instruction is most important to include in her teaching?

  1. Perform vaginal self-examinations each evening
  2. Report any fever, uterine tenderness, or foul-smelling discharge Correct answer.
  3. Avoid all oral fluids to reduce leaking
  4. Take a tub bath daily to keep the area clean

Explanation

After membrane rupture, infection is the major risk, and fever, tenderness, or malodorous discharge are warning signs of chorioamnionitis. Prompt reporting allows early treatment.

Question 13Antepartum Care

A client at 9 weeks' gestation has a positive pregnancy test but an empty uterine cavity on transvaginal ultrasound and a very high hCG. Which diagnosis should the nurse anticipate?

  1. Threatened abortion
  2. Molar pregnancy
  3. Missed abortion
  4. Ectopic pregnancy Correct answer.

Explanation

An empty uterus with a high hCG level suggests the pregnancy is implanted outside the uterus, most often in a fallopian tube. Ectopic pregnancy is a medical emergency because of rupture risk.

Question 14Antepartum Care

A client treated with methotrexate for a small unruptured ectopic pregnancy calls reporting severe one-sided pelvic pain and dizziness. What should the nurse advise?

  1. Come to the emergency department immediately Correct answer.
  2. Wait for the next scheduled hCG level in 48 hours
  3. Take prescribed pain medication and rest at home
  4. Apply a heating pad to the abdomen and monitor

Explanation

Severe unilateral pain with dizziness after methotrexate raises concern for tubal rupture and internal bleeding, which is life-threatening. Immediate emergency evaluation is required.

Question 15Antepartum Care

Which immunization is recommended during pregnancy to protect the newborn from pertussis?

  1. MMR in the first trimester
  2. Tdap between 27 and 36 weeks Correct answer.
  3. Varicella at 20 weeks
  4. Live attenuated influenza by injection

Explanation

Tdap is recommended in each pregnancy, ideally at 27 to 36 weeks, so maternal antibodies transfer to the fetus. Live vaccines are avoided during pregnancy.

Question 16Antepartum Care

A client at 13 weeks' gestation is Rh negative and unsensitized. When is Rho(D) immune globulin indicated for routine prophylaxis?

  1. Only after a first-trimester miscarriage
  2. Only if the client reports vaginal bleeding
  3. At about 28 weeks and within 72 hours after delivery of an Rh-positive infant Correct answer.
  4. At 8 weeks and again at 16 weeks

Explanation

Routine antenatal prophylaxis is given around 28 weeks, and a postpartum dose is given within 72 hours when the newborn is Rh positive. Additional doses follow events such as amniocentesis or bleeding.

Question 17Antepartum Care

A client at 36 weeks' gestation reports that her fetus has been less active today. What is the most appropriate initial instruction?

  1. Perform a focused fetal movement count and report results Correct answer.
  2. Drink a large amount of caffeine to stimulate the fetus
  3. Lie flat on the back for two hours
  4. Wait until the next scheduled appointment

Explanation

Reduced fetal movement warrants prompt assessment, beginning with a focused movement count and, if decreased, further testing such as a nonstress test. Maternal perception of decreased movement is a warning sign.

Question 18Antepartum Care

Which client statement indicates a correct understanding of a nonstress test?

  1. The test is done only during active labor
  2. The test measures how the fetal heart rate responds to fetal movement Correct answer.
  3. The test requires an injection of oxytocin before it begins
  4. The test measures the strength of my uterine contractions

Explanation

A nonstress test records the fetal heart rate and its accelerations in response to fetal movement, reflecting fetal well-being. It is a common antepartum surveillance tool.

Question 19Antepartum Care

A client at 24 weeks' gestation asks about screening for neural tube defects. Which statement is most accurate?

  1. Screening is recommended only for clients over age 40
  2. Maternal serum alpha-fetoprotein screening is typically offered at 15 to 20 weeks Correct answer.
  3. Amniocentesis at 8 weeks is the standard screening test
  4. Neural tube defects cannot be screened for before birth

Explanation

Maternal serum alpha-fetoprotein is measured in the second trimester, generally 15 to 20 weeks, to screen for open neural tube defects. Ultrasound and amniotic fluid testing can provide further information.

Question 20Antepartum Care

A client at 10 weeks' gestation is prescribed folic acid. Which dose is recommended for a client with a prior pregnancy affected by a neural tube defect?

  1. 0.4 mg daily beginning at 12 weeks
  2. 1 mg weekly throughout pregnancy
  3. 4 mg daily beginning before conception Correct answer.
  4. No supplement is needed

Explanation

A high-dose folic acid supplement of 4 mg daily is recommended for clients with a prior neural tube defect-affected pregnancy, started before conception and continued early in pregnancy. Standard supplementation is 0.4 mg daily.

Question 21Antepartum Care

A client at 14 weeks' gestation reports occasional spotting after intercourse and mild cramping. Which response is most appropriate?

  1. Report any heavy bleeding, passage of tissue, or worsening pain promptly Correct answer.
  2. Stop all prenatal vitamins until the spotting resolves
  3. Schedule an elective induction of labor
  4. This always means the pregnancy is lost

Explanation

Light spotting can occur with cervical friability in pregnancy, but heavy bleeding, tissue passage, or worsening pain suggest threatened abortion and require prompt evaluation. Teaching should focus on warning signs.

Question 22Antepartum Care

A client at 32 weeks' gestation has a biophysical profile score of 4 out of 10. What is the most appropriate interpretation?

  1. The score is abnormal and requires further evaluation Correct answer.
  2. The score indicates a multifetal gestation
  3. The score confirms ruptured membranes
  4. The score is normal and reassuring

Explanation

A biophysical profile score of 4 or less is abnormal and suggests fetal compromise, prompting further testing and possible delivery planning. Scores of 8 to 10 are generally reassuring.

Question 23Antepartum Care

Which finding on a prenatal visit at 22 weeks' gestation should prompt evaluation for anemia?

  1. Hemoglobin of 9.8 g/dL Correct answer.
  2. Hemoglobin of 11.8 g/dL
  3. Blood pressure of 112/70 mm Hg
  4. Fundal height of 22 cm

Explanation

Physiologic anemia of pregnancy lowers hemoglobin modestly, but a value below about 10.5 g/dL in the second trimester suggests true anemia and warrants iron studies and further workup.

Question 24Antepartum Care

A client at 20 weeks' gestation reports heartburn after meals. Which instruction should the nurse provide?

  1. Drink a large glass of milk with each meal to neutralize acid
  2. Lie down immediately after eating to aid digestion
  3. Take a daily aspirin to reduce stomach acid
  4. Eat smaller meals and avoid lying down for 1 to 2 hours after eating Correct answer.

Explanation

Progesterone relaxes the lower esophageal sphincter and the enlarging uterus increases intra-abdominal pressure, so smaller meals and remaining upright after eating reduce reflux. Antacids may be added if needed.

Question 25Antepartum Care

A client at 28 weeks' gestation with a history of preterm birth is being evaluated for preterm labor prevention. Which intervention is most appropriate to discuss?

  1. Avoiding all prenatal visits until 36 weeks
  2. Progesterone supplementation as prescribed Correct answer.
  3. Routine bed rest for the remainder of pregnancy
  4. Elective delivery at 34 weeks

Explanation

Progesterone supplementation is recommended for clients with a prior singleton preterm birth to reduce recurrence risk. Bed rest has not been shown to prevent preterm birth and carries risks.

Question 26Antepartum Care

A client at 10 weeks' gestation reports nausea and vomiting that occurs mostly in the morning. Which instruction should the nurse give first?

  1. Skip breakfast and drink only clear fluids until noon.
  2. Lie down immediately after each meal.
  3. Take a prenatal vitamin on an empty stomach.
  4. Eat small, frequent meals and dry crackers before rising. Correct answer.

Explanation

First-line management of mild nausea and vomiting of pregnancy includes dietary measures such as small frequent meals and dry carbohydrate snacks before arising to reduce gastric irritation. These strategies are safe and effective before antiemetics are considered.

Question 27Antepartum Care

A client at 8 weeks' gestation asks when the fetal heart rate can first be detected by Doppler auscultation. Which response is most accurate?

  1. Usually between 18 and 20 weeks' gestation.
  2. Usually between 6 and 7 weeks' gestation.
  3. Usually between 14 and 16 weeks' gestation.
  4. Usually between 10 and 12 weeks' gestation. Correct answer.

Explanation

Handheld Doppler auscultation of the fetal heart rate is typically possible by 10 to 12 weeks' gestation. Earlier detection is unreliable and may cause unnecessary anxiety.

Question 28Antepartum Care

A client at 12 weeks' gestation has a body mass index of 32 kg/m². Which prenatal nutrition instruction is most appropriate?

  1. Maintain prepregnancy weight throughout pregnancy.
  2. Aim for a total weight gain of 11 to 16 kg (25 to 35 lb).
  3. Increase daily caloric intake by 1000 kcal over prepregnancy needs.
  4. Limit weight gain to about 5 to 9 kg (11 to 20 lb) during pregnancy. Correct answer.

Explanation

For a client with obesity (BMI 30 or greater), the Institute of Medicine recommends a total gestational weight gain of about 5 to 9 kg (11 to 20 lb). This range balances fetal growth needs against maternal risks of excessive gain.

Question 29Antepartum Care

A client at 16 weeks' gestation reports a burning sensation in the chest after eating. Which instruction should the nurse provide?

  1. Avoid all dairy products until the symptom resolves.
  2. Drink a full glass of water with each meal to dilute stomach acid.
  3. Lie down for 20 minutes after meals to aid digestion.
  4. Eat smaller meals and remain upright for 30 minutes after eating. Correct answer.

Explanation

Heartburn in pregnancy is reduced by smaller meals and avoiding recumbency after eating, which limits reflux of gastric contents. These measures are safe and effective first steps.

Question 30Antepartum Care

A client at 14 weeks' gestation has a hemoglobin of 10.8 g/dL and a mean corpuscular volume of 72 fL. Which condition is most likely?

  1. Thalassemia trait
  2. Folate deficiency anemia
  3. Anemia of chronic disease
  4. Iron deficiency anemia Correct answer.

Explanation

Microcytic anemia with a low MCV in pregnancy most commonly reflects iron deficiency. Thalassemia trait also causes microcytosis but is less common and typically has a normal or elevated red cell count; iron studies help confirm.

Question 31Antepartum Care

A client at 24 weeks' gestation asks about the purpose of a 1-hour glucose challenge test. Which statement by the nurse is most accurate?

  1. It screens for gestational diabetes and may be followed by a longer diagnostic test if elevated. Correct answer.
  2. It diagnoses gestational diabetes without the need for further testing.
  3. It measures thyroid function during pregnancy.
  4. It assesses fetal lung maturity before delivery.

Explanation

The 50-g glucose challenge is a screening test; an elevated result requires a diagnostic 100-g, 3-hour oral glucose tolerance test. It does not by itself diagnose gestational diabetes.

Question 32Antepartum Care

A client at 26 weeks' gestation with a history of preterm birth is prescribed vaginal progesterone. Which instruction should the nurse include?

  1. Use the medication daily at bedtime as prescribed. Correct answer.
  2. Stop the medication if vaginal discharge increases.
  3. Double the dose if symptoms of preterm labor appear.
  4. Take the medication only when contractions occur.

Explanation

Vaginal progesterone for prevention of recurrent preterm birth is used daily, often at bedtime, throughout the recommended gestational period. It is not a PRN treatment for contractions.

Question 33Antepartum Care

A client at 22 weeks' gestation has a blood pressure of 142/92 mm Hg on two occasions 4 hours apart and no proteinuria. Which condition is most consistent with these findings?

  1. Chronic hypertension
  2. White-coat hypertension
  3. Preeclampsia without severe features
  4. Gestational hypertension Correct answer.

Explanation

New hypertension after 20 weeks without proteinuria or other end-organ dysfunction is classified as gestational hypertension. Chronic hypertension would predate pregnancy or appear before 20 weeks.

Question 34Antepartum Care

A client at 18 weeks' gestation is scheduled for a maternal serum alpha-fetoprotein test. Which instruction should the nurse provide?

  1. The test must be done after 24 weeks' gestation.
  2. The test requires an overnight fast.
  3. The test is most accurate between 16 and 18 weeks' gestation. Correct answer.
  4. The test replaces the need for an anatomy ultrasound.

Explanation

Maternal serum alpha-fetoprotein screening is optimally performed between 15 and 20 weeks, with 16 to 18 weeks being the most sensitive window. It is a screening test and does not replace ultrasound.

Question 35Antepartum Care

A client at 30 weeks' gestation reports increased vaginal discharge without itching or odor. Which response by the nurse is most appropriate?

  1. Explain that increased clear or white discharge is common in pregnancy. Correct answer.
  2. Recommend a course of antibiotics without evaluation.
  3. Tell the client to douche with vinegar and water daily.
  4. Advise the client to use scented panty liners.

Explanation

Leukorrhea, an increase in clear or white vaginal discharge, is a normal physiologic change of pregnancy related to increased estrogen and vascularity. Douching and scented products can disrupt flora and are not recommended.

Question 36Antepartum Care

A client at 34 weeks' gestation reports regular uterine contractions every 5 minutes that resolve with rest and hydration. Which interpretation is most appropriate?

  1. This suggests placental abruption and requires emergency cesarean birth.
  2. This is a sign of uterine rupture and requires immediate surgery.
  3. This indicates active preterm labor requiring immediate delivery.
  4. These are likely Braxton Hicks contractions and can be managed at home. Correct answer.

Explanation

Contractions that are irregular or resolve with rest and hydration are characteristic of Braxton Hicks contractions. Preterm labor contractions typically persist despite these measures and are accompanied by cervical change.

Question 37Antepartum Care

A client at 20 weeks' gestation has a fundal height of 24 cm. Which factor most likely explains this finding?

  1. Fetal growth restriction
  2. Inaccurate dating with a post-term fetus
  3. Multiple gestation Correct answer.
  4. Oligohydramnios

Explanation

A fundal height that exceeds gestational age by more than 2 to 3 cm may indicate multiple gestation, polyhydramnios, or macrosomia. Oligohydramnios and growth restriction typically cause a smaller-than-expected fundal height.

Question 38Antepartum Care

A client at 28 weeks' gestation with preeclampsia is prescribed betamethasone. Which statement by the nurse best explains the purpose?

  1. It lowers maternal blood pressure within 24 hours.
  2. It resolves proteinuria in preeclampsia.
  3. It treats maternal seizures associated with preeclampsia.
  4. It accelerates fetal lung maturity in case preterm delivery is needed. Correct answer.

Explanation

Antenatal corticosteroids such as betamethasone stimulate surfactant production and reduce neonatal respiratory distress syndrome, intraventricular hemorrhage, and mortality when preterm birth is anticipated. They do not treat maternal hypertension, seizures, or proteinuria.

Question 39Antepartum Care

A client at 36 weeks' gestation with a singleton fetus and breech presentation asks about options for turning the baby. Which procedure should the nurse anticipate discussing?

  1. Vacuum extraction
  2. Internal version
  3. Forceps rotation
  4. External cephalic version Correct answer.

Explanation

External cephalic version is an attempt to turn a breech fetus to cephalic presentation by applying pressure to the maternal abdomen, typically near term. Internal version and operative vaginal delivery are used during labor, not for antepartum version.

Question 40Antepartum Care

A client at 32 weeks' gestation is Rh negative and has a negative antibody screen. She received Rho(D) immune globulin at 28 weeks. She now reports a small amount of vaginal bleeding after a fall. Which action is most appropriate?

  1. Reassure her that no further treatment is needed.
  2. Schedule Rho(D) immune globulin for after delivery only.
  3. Administer an additional dose of Rho(D) immune globulin. Correct answer.
  4. Obtain a repeat antibody screen before any intervention.

Explanation

Any fetomaternal hemorrhage, such as from trauma or bleeding, may require an additional dose of Rho(D) immune globulin in an Rh-negative unsensitized client. The dose may be guided by a Kleihauer-Betke or flow cytometry test, but administration should not be delayed.

Question 41Intrapartum Care

A nurse notes a fetal heart rate baseline of 150 bpm with moderate variability and no decelerations. How is this tracing classified under the three-tier system?

  1. Category II
  2. Category I Correct answer.
  3. Category III
  4. Category IV

Explanation

Category I requires a baseline of 110–160 bpm, moderate variability, no late or variable decelerations, and either accelerations or no accelerations with a reassuring pattern. Absent decelerations and moderate variability make this tracing normal. Categories II and III denote indeterminate or abnormal patterns, and there is no Category IV in the standard three-tier system.

Question 42Intrapartum Care

During labor, a nurse observes a fetal heart rate deceleration that begins after the peak of the contraction and returns to baseline after the contraction ends. What is the correct interpretation?

  1. Variable deceleration
  2. Early deceleration
  3. Acceleration
  4. Late deceleration Correct answer.

Explanation

Late decelerations are defined by their timing: onset after the contraction begins, nadir after the contraction peak, and recovery after the contraction ends. This timing reflects uteroplacental insufficiency. Early decelerations mirror the contraction and are benign head-compression responses.

Question 43Intrapartum Care

A laboring patient has a Category II tracing with recurrent late decelerations. Which initial nursing action is most appropriate?

  1. Prepare for immediate cesarean delivery without further assessment
  2. Increase oxytocin to shorten labor
  3. Reposition the patient to a lateral position and administer oxygen Correct answer.
  4. Document and continue monitoring without intervention

Explanation

Recurrent late decelerations suggest uteroplacental insufficiency, and intrauterine resuscitation begins with maternal repositioning (lateral), oxygen administration, and stopping uterotonic agents. These measures improve uteroplacental blood flow. Immediate cesarean is reserved for Category III or failure of resuscitation.

Question 44Intrapartum Care

Which finding is characteristic of a normal uterine contraction pattern in active labor?

  1. Contractions every 1 minute lasting 90 seconds
  2. Contractions every 2–3 minutes lasting 45–60 seconds Correct answer.
  3. Contractions every 10 minutes lasting 30 seconds
  4. Tetanic contraction lasting 3 minutes

Explanation

Normal active labor contractions occur approximately every 2–3 minutes and last 45–60 seconds, with relaxation between them. Adequate relaxation allows restoration of uteroplacental perfusion. Tetanic or excessively frequent contractions risk fetal hypoxia.

Question 45Intrapartum Care

A nurse is assessing a patient in the first stage of labor. Which finding indicates the transition to the second stage?

  1. Bloody show
  2. Rupture of membranes
  3. Complete cervical dilation with urge to bear down Correct answer.
  4. Contractions every 5 minutes

Explanation

The second stage of labor begins at full cervical dilation (10 cm) and ends with delivery of the infant. An urge to bear down typically accompanies complete dilation as the presenting part descends. Rupture of membranes and bloody show can occur at any point and do not define stage transition.

Question 46Intrapartum Care

Which parameter is used to determine the station of the fetal presenting part?

  1. Frequency of uterine contractions
  2. Degree of cervical effacement
  3. Relationship of the presenting part to the ischial spines Correct answer.
  4. Position of the fetal occiput relative to the maternal pelvis

Explanation

Station describes the level of the fetal presenting part relative to the maternal ischial spines, measured in centimeters from −5 to +5. Zero station indicates the presenting part is at the level of the spines. Effacement, position, and contraction frequency are separate assessments.

Question 47Intrapartum Care

A patient at 39 weeks presents with spontaneous rupture of membranes and clear fluid. What is the priority nursing action?

  1. Assess fetal heart rate and document time and characteristics of rupture Correct answer.
  2. Administer a tocolytic agent
  3. Encourage ambulation without assessment
  4. Perform a sterile vaginal examination to assess dilation

Explanation

After spontaneous rupture of membranes, the priority is to assess fetal status and document the time, color, and amount of fluid. This establishes a baseline and identifies cord prolapse or meconium. Sterile examination follows assessment and is performed judiciously to reduce infection risk.

Question 48Intrapartum Care

Which finding suggests umbilical cord prolapse during labor?

  1. Mild increase in maternal blood pressure
  2. Sudden onset of severe variable decelerations or bradycardia after membrane rupture Correct answer.
  3. Gradual increase in baseline variability
  4. Contractions that become more regular

Explanation

Cord prolapse compresses the umbilical vessels, producing abrupt variable decelerations or sustained bradycardia, often immediately after membrane rupture. It is an obstetric emergency requiring repositioning and immediate delivery. Increased variability or regular contractions are not signs of prolapse.

Question 49Intrapartum Care

A patient in active labor has a cervical exam showing 6 cm dilation, 80% effacement, and 0 station. Contractions are every 3 minutes. What is the appropriate interpretation?

  1. Prodromal labor
  2. Latent phase of the first stage of labor
  3. Second stage of labor
  4. Active phase of the first stage of labor Correct answer.

Explanation

The active phase of the first stage begins at approximately 6 cm dilation with regular contractions and progressive cervical change. Latent phase precedes 6 cm, and the second stage begins at full dilation. This exam represents normal active-phase progress.

Question 50Intrapartum Care

Which maternal position is most likely to optimize fetal descent and reduce the risk of prolonged second stage?

  1. Trendelenburg position
  2. Lithotomy with prolonged breath holding
  3. Upright or squatting position Correct answer.
  4. Supine with legs extended

Explanation

Upright and squatting positions use gravity and increase pelvic outlet dimensions, promoting fetal descent and more efficient pushing. Supine positioning can compress the vena cava and reduce uterine perfusion. Lithotomy with prolonged breath holding is associated with fetal desaturation.