Module 5 Kelsey Chapter 8

Question 1

Your client, who you are co-managing with your consulting physician, is 33 weeks and 4 days pregnant. She is admitted with premature labor, with a cervical exam of 2–3 cm/80%/–1, vertex, intact. She is currently on MgSO4 at 3.0 g/hour with occasional contractions. During rounds, she complains of feeling flushed and hot; lethargic; and short of breath, with this sensation usually getting better when she changes position. Which response would be best to address her complaints?

A) “The MgSO4 commonly makes you feel like this, but hopefully they will start weaning the medication today.”
B) “Well, because you are almost 34 weeks, I could ask the doctor if we can discontinue the medication now.”
C) “I do not think that you should be having shortness of breath; I am going to have the physician see you and order a chest radiograph.”
D) “Being a little uncomfortable is so much better than giving birth to a 33-week-old infant.”

Answer 1

C) “I do not think that you should be having shortness of breath; I am going to have the physician see you and order a chest radiograph.”

Shortness of breath is not a typical side effect of magnesium sulfate and should be investigated.

Question 2

In the second stage of labor, how frequently should the blood pressure of low-risk women be checked?

A) Every 30 minutes
B) Every 2 minutes
C) Every 60 minutes
D) Every 15 minutes

Answer 2

D) Every 15 minutes

Blood pressure should be evaluated every 15 minutes in the second stage of labor for low-risk women.

Question 3

Mrs. Hogan, a 37-year-old G4 P0 at 35 weeks, presents saying that she has been having bright red bleeding and clots for 2 hours since intercourse with her husband. She has saturated two pads in 2 hours. She is not having any pain. The most probable diagnosis is:

A) placenta previa.
B) cervical irritation from intercourse.
C) placental abruption.
D) normal bloody show.

Answer 3

A) placenta previa.

With placenta previa, painless vaginal bleeding occurs 70% to 80% of the time.

Question 4

A client who is a G3 P2002 at 38 weeks presents with regular uterine contractions every 4 to 6 minutes for 60 seconds for the past 8 hours. Their vaginal exam is 2 cm/30%/–2, vertex with intact membranes. They are very uncomfortable with the contractions and declines discharge to home at this time. Your management plan at this time is to:

A) admit the client immediately.
B) have the client ambulate for 2 hours and then reassess the client.
C) contact the consulting physician for augmentation of labor.
D) defer to the client’s birth plan.

Answer 4

B) have the client ambulate for 2 hours and then reassess the client.

Ambulation for 2 hours allows the clinician to evaluate for cervical change (definition of labor). The client’s perception of need for admission to the birthing facility is also important in clinical decision making.

Question 5

All of the following are risk factors for preterm labor except:

A) age.
B) smoking.
C) race.
D) sex of the fetus.

Answer 5

D) sex of the fetus.

The other risk factors—age, smoking, and race—are evidence-based risk factors for preterm labor. Research does not support sex of the fetus as a risk factor for preterm labor

Question 6

When is the most optimal time to administer pudendal anesthesia for perineal pain relief in the multiparous client?

A) For the repair of any laceration or episiotomy
B) When the head distends the perineum and the client complains of the “ring of fire”
C) When the vertex is at +2
D) At approximately 8–9 cm dilated

Answer 6

D) At approximately 8–9 cm dilated

The optimal timing for administration of pudendal anesthesia is just before complete dilation in a multiparous client because it provides coverage for the birth as well as any repair needed.

Question 7

The bluish discoloration of the baby’s hands and feet within the first 24–48 hours after birth is:

A) acrocyanosis.
B) circumoral cyanosis.
C) central cyanosis.
D) Mongolian spots.

Answer 7

A) acrocyanosis.

Bluish discoloration of the baby’s hands and feet, known as acrocyanosis, is normal in the first 24–48 hours after birth.

Question 8

Your client is in active labor and is making appropriate progress. Currently, their exam is 6 cm/100%/2, vertex with intact membranes. During your exam, you notice the position of the vertex is LOT and the sagittal suture of the fetus is closer to the maternal sacrum. Your diagnosis at this time is:

A) deep transverse pelvic arrest.
B) anterior asynclitism.
C) failure to descend.
D) posterior asynclitism.

Answer 8

B) anterior asynclitism.

Anterior asynclitism is noted when the sagittal suture is closer to the sacrum.

Question 9

The benefit of placing an internal scalp electrode on a fetus in labor is:

A) the ability to have a continuous tracing when external monitoring is insufficient.
B) the ability to detect decelerations.
C) that it keeps the client in bed.
D) the ability to assess variability.

Answer 9

A) the ability to have a continuous tracing when external monitoring is insufficient.

An internal scalp electrode allows for accurate, continuous fetal monitoring when an external monitor is not producing a reliable continuous tracing.

Question 10

The following is the clinical picture of your client. She is a G1 P0 at 39 weeks with an uncomplicated pregnancy. Her labor started at 4:00 a.m. with regular contractions. She was admitted at 8:00 a.m., when her exam was 2–3 cm/100%/–2 station, vertex, membranes intact.
At 12:00 p.m., her exam was 3–4 cm/100%/–2, intact.
At 4:00 p.m., her exam was 4 cm/100%/–2, intact.
At 7:30 p.m., her exam was 5–6 cm/100%/–1, intact. At 8:15 p.m., she ruptured membranes, producing light ­meconium-stained fluid.
At 10:00 p.m., her exam was 8 cm/100%/0 station.
At 10:00 p.m., the client requests something for pain because she states that the pain is intolerable now and she is feeling increased pelvic pressure.
What would not be indicated for pain relief at this time?

A) Epidural anesthesia
B) Intravenous opioids
C) Pudendal anesthesia
D) Paracervical block

Answer 10

B) Intravenous opioids

Intravenous opioids should not be used when birth is anticipated within an hour because of the risk for respiratory depression in the newborn.

Question 11

The process of involution takes place over which of the following time frames?

A) The first 6 weeks postpartum
B) The first 24 hours postpartum
C) The first 2 weeks postpartum
D) The first year postpartum

Answer 11

A) The first 6 weeks postpartum

Normal postpartum involution takes a full 6 weeks to be complete.

Question 12

In the initial newborn period, a 10-minute Apgar score is performed:

A) routinely.
B) if the 1-minute Apgar score is less than 7.
C) if the 5-minute Apgar score is less than 7.
D) if the combined Apgar score at 1 and 5 minutes is less than 16.

Answer 12

C) if the 5-minute Apgar score is less than 7.

Apgar scores are performed routinely at 1 and at 5 minutes, with a 10-minute Apgar scoring usually performed only if the 5-minute Apgar score is less than 7.

Question 13

When an IUPC is used for the assessment of uterine contractions, the adequacy is quantified:

A) in mm of mercury.
B) as mild, moderate, and strong.
C) in mVu.
D) in cm.

Answer 13

C) in mVu.

Whereas the IUPC quantifies the strength of the contractions in millimeters of mercury, adequacy is determined by the average number of mVu over a 10-minute period.

Question 14

Which of the following would not be included in the differential diagnosis of premature labor?

A) Urinary tract infection
B) Appendicitis
C) Renal colic
D) Heartburn

Answer 14

D) Heartburn

he other conditions—urinary tract infection, appendicitis, and renal colic—may mimic the signs and symptoms of preterm labor, whereas heartburn does not.

Question 15

Your client, who is 41 weeks and 5 days pregnant, presents for postdates testing, including an NST. When you assess the tracing after 20 minutes, the FHR is 140–145 bpm, there are no decelerations, and the variability is moderate, but the tracing does not meet criteria for reactivity. What would you do?

A) Admit the client and induce labor.
B) Begin a contraction stress test.
C) Use the vibroacoustic stimulator.
D) Continue the NST for another 20 minutes.

Answer 15

D) Continue the NST for another 20 minutes.

The fetus has sleep/wake cycles, so nonreactivity may be due to fetal sleep. Extending the time of the test is common practice to account for this possibility.

Question 16

Which of the following sequences represents the cardinal movements of labor and birth for the occiput anterior position?

A) Flexion, descent, internal rotation, extension, restitution, external rotation
B) Descent, flexion, extension, internal rotation, external rotation, restitution
C) Descent, flexion, internal rotation, extension, restitution, external rotation
D) Descent, flexion, internal rotation, extension, external rotation, restitution

Answer 16

C) Descent, flexion, internal rotation, extension, restitution, external rotation

The cardinal movements of labor are descent, flexion, internal rotation, extension, restitution, and external rotation.

Question 17

Ryan Jones, a G3 P2002 at 37 weeks and 1 day, presents to the labor and delivery service with regular contractions every 2 to 3 minutes for 5 hours. Your vaginal exam reveals 6 cm/100%/–2, LSA with ruptured membranes positive for light meconium. What is your next step?

A) Admit the client for expectant management.
B) Discuss the birth plan with the client.
C) Await a reactive tracing before making a management plan.
D) Notify the consulting physician and prepare for a cesarean section.

Answer 17

D) Notify the consulting physician and prepare for a cesarean section.

LSA indicates that the fetus is in breech presentation. At 6 cm, ­delivery is not imminent; thus a cesarean birth is indicated.

Question 18

The definition of postpartum hemorrhage is blood loss:

A) that causes the patient to be hemodynamically symptomatic.
B) in excess of 750 mL during the entire labor.
C) of more than 500 mL after a cesarean section.
D) of 750 mL or more after the third stage of labor.

Answer 18

A) that causes the patient to be hemodynamically symptomatic.

The current definition of PPH is excessive, delivery-related blood loss that causes the patient to be hemodynamically symptomatic and/or hypovolemic (Gabbe et al., 2017).

Question 19

Mothers in premature labor are given glucocorticosteroids to:

A) help stop the uterine contractions.
B) prevent infections, especially chorioamnionitis.
C) speed the maturation of the fetal respiratory system, including the production of surfactant.
D) prevent the muscle wasting commonly seen in patients on bed rest.

Answer 19

C) speed the maturation of the fetal respiratory system, including the production of surfactant.

Question 20

A client is seen in labor and delivery at 33 weeks and 1 day complaining of menstrual-type cramping for the past 3 hours. She denies bleeding or ruptured membranes. The fetus is active. The EFM reveals occasional uterine contractions approximately every 8–12 minutes. The FHR is 135–140 bpm. Which of the following tests would be most important in formulating your management plan?

A) Complete blood count
B) Cervical culture
C) Urine culture
D) Ultrasound

Answer 20

C) Urine culture

A urinary tract infection can mimic—and is a risk factor for—­preterm labor.

Question 21

What is the largest group of muscles in the pelvic musculature?

A) Levator ani
B) Pubococcygeus
C) Bulbocavernosus
D) Sphincter ani

Answer 21

A) Levator ani

Question 22

Infants born to mothers with gestational diabetes are at increased risk for:

A) hypothermia.
B) IUGR.
C) hyperglycemia.
D) shoulder dystocia.

Answer 22

D) shoulder dystocia.

Question 23

A client is seen in labor and delivery at 33 weeks and 4 days reporting menstrual-type cramping for the past 5 hours. She denies bleeding or ruptured membranes. The fetus is active. The EFM reveals occasional uterine contractions approximately every 8–12 minutes. The FHR is 120–140 bpm. What would be the next step in your management plan for this patient?

A) Expectant management until the lab results are back
B) Tocolysis
C) Pain management
D) Additional information is necessary to formulate the management plan.

Answer 23

D) Additional information is necessary to formulate the management plan.

Question 24

In the first stage of labor for low-risk laboring women, the interval for intermittent FHR auscultation is:

A) 15 minutes.
B) 20 minutes.
C) 30 minutes.
D) 60 minutes.

Answer 24

C) 30 minutes.

Question 25

What is the major risk of multifetal gestation?

A) Eclampsia
B) Gestational diabetes
C) Cephalopelvic disproportion
D) Preterm birth

Answer 25

D) Preterm birth

Question 26

If a nuchal arm is encountered during an assisted breech birth, what should you do?

A) Exert steady downward traction on the entire fetus.
B) Slowly rotate the infant 180 degrees to attempt to dislodge the arm.
C) Raise the baby in a warm towel above the plane of the vagina.
D) Sweep the arm down by hooking the elbow and pulling the arm down.

Answer 26

D) Sweep the arm down by hooking the elbow and pulling the arm down.

It is important to remain calm and guide the arm in a physiologic range of motion.

Question 27

The most common cause of postpartum hemorrhage is:

A) sulcus tears.
B) episiotomy extensions to third- and fourth-degree lacerations.
C) uterine atony.
D) cervical lacerations.

Answer 27

C) uterine atony.

Question 28

With internal monitoring of uterine contractions, which of the following levels must be achieved in the course of 10 minutes to be considered adequate contractile strength to dilate the cervix?

A) 80–100 mVu
B) 80–100 mm Hg
C) 200–250 mVu
D) 200–250 mm Hg

Answer 28

C) 200–250 mVu

Adequate contraction strength is indicated by 200–250 mVu over a 10-minute period.

Question 29

Your client is in active labor and is making appropriate progress. Currently, their exam is 6 cm/100%/2, vertex with intact membranes. During your exam, you notice the position of the vertex is LOT and the sagittal suture of the fetus is closer to the maternal sacrum. On the fetal monitor strip, you notice the FHR has intermittently been 100–110 bpm for 20–30 seconds at a time for the past 10–15 minutes with good return to the baseline of 140 bpm. You would document this as:

A) variable decelerations.
B) late decelerations.
C) fetal bradycardia.
D) You cannot determine how to document from this information.

Answer 29

A) variable decelerations.

Variable decelerations are abrupt in nature with a decrease in FHR from a baseline of ≥ 15 bpm lasting ≥ 15 seconds but < 2 minutes.

Question 30

Moderate variability of the FHR is a change of how many beats per minute from the baseline?

A) Fewer than 2 bpm
B) 2–6 bpm
C) 6–25 bpm
D) > 25 bpm

Answer 30

C) 6–25 bpm

Question 31

The most favorable diameter of the fetal head to present in labor is the:

A) verticomental.
B) submentobregmatic.
C) occipitofrontal.
D) suboccipitobregmatic.

Answer 31

D) suboccipitobregmatic.

When the fetal head meets the resistance of the pelvic floor, flexion is encouraged so that the most favorable diameter (suboccipitobregmatic) presents.

Question 32

The following is the clinical picture of your client. She is a G1 P0 at 39 weeks with an uncomplicated pregnancy. Her labor started at 4:00 a.m. with regular contractions. She was admitted at 8:00 a.m., when her exam was 2–3 cm/100%/–2 station, vertex, membranes intact.
At 12:00 p.m., her exam was 3–4 cm/100%/–2, intact.
At 4:00 p.m., her exam was 4 cm/100%/–2, intact.
At 7:30 p.m., her exam was 5–6 cm/100%/–1, intact.
At 8:15 p.m., she ruptured membranes, producing light meconium-stained fluid.
At 10:00 p.m., her exam was 8 cm/100%/0 station.
Based on the information provided, at 12:00 p.m. what was the most appropriate diagnosis related to this client’s labor progress?

A) Latent phase
B) Protracted latent phase
C) Unable to make determination with this information
D) Active labor

Answer 32

A) Latent phase

The latent phase of labor is from the onset of labor until cervical dilation reaches 4–6 cm.

Question 33

Your client is in active labor and is making appropriate progress. Currently, their exam is 6 cm/100%/2, vertex with intact membranes. During your exam, you notice the position of the vertex is LOT and the sagittal suture of the fetus is closer to the maternal sacrum. What is the next step to managing this patient?

A) artificial rupture of membranes.
B) epidural anesthesia.
C) Pitocin augmentation.
D) to encourage movement and position change.

Answer 33

D) to encourage movement and position change.

Movement and position change can encourage the fetus to descend into a favorable position for birth.

Question 34

A client presents to your office stating that she is pregnant, and she wants to know her due date. The first day of her last period was February 4. Her due date by menstrual dating (Naegele’s rule) is:

A) November 11.
B) October 28.
C) May 11.
D) November 4.

Answer 34

A) November 11.

Naegele’s rule is to add 7 days to the first day of the last menstrual period and subtract 3 months.

Question 35

Which of the following would represent a contraindication to the use of an IUPC?

A) Maternal birth plan
B) Breech presentation
C) Maternal HIV infection
D) Lack of labor progress

Answer 35

C) Maternal HIV infection

Attempts should be made to minimize possible transmission of maternal blood to the fetus, which could occur with placement of an IUPC.

Question 36

If you are performing scalp stimulation, what is the fetal response that indicates fetal well-being?

A) An FHR deceleration to 100 bpm for 2 minutes
B) An FHR acceleration of 5 bpm over baseline for 5 seconds
C) A variable deceleration
D) An FHR acceleration of 15 bpm for 15 seconds

Answer 36

D) An FHR acceleration of 15 bpm for 15 seconds

A FHR acceleration indicates a fetal pH ≥ 7.20.

Question 37

A client presents while you are covering labor and delivery. She is a 33-year-old G3 P2002 at term, and in labor with ruptured membranes. Your exam reveals 5 cm/90% effaced/0 station, but you are unable to palpate fontanels or sutures. You suspect that you feel the orbital ridge in the anteroposterior diameter and the chin at 3 o’clock. Three hours later, the client is completely dilated/100% ­effaced/0 station with an urge to push. Your exam now reveals that the presentation is MA. What would your next step be?

A) Prepare the client for urgent cesarean section.
B) Manually attempt to flex the fetal head.
C) Encourage the client to push as effectively as possible.
D) Allow the client to push only in the hands-and-knees position to allow the fetal head to rotate.

Answer 37

C) Encourage the client to push as effectively as possible.

More than 90% of anterior face presentations deliver vaginally without complications (Posner, Dy, Black, & Jones, 2013, p. 250).

Note: You cannot deliver vaginally with MP position

Question 38

The denominator of breech presentation is the:

A) symphysis pubis.
B) sacrum.
C) feet.
D) shoulders.

Answer 38

B) sacrum.

Question 39

The pain of the second stage of labor is caused by:

A) uterine muscle hypoxia with lactic acid buildup and distention of the musculature of the pelvic floor.
B) a full bladder.
C) pressure on the bony pelvis, urethra, bladder, and rectum.
D) fundal uterine displacement and extension of the fetal lie.

Answer 39

C) pressure on the bony pelvis, urethra, bladder, and rectum.

Question 40

The risk factor that is most predictive of a preterm birth during a current pregnancy is:

A) uterine contractions.
B) prior preterm labor.
C) prior preterm birth.
D) gestational hypertension.

Answer 40

C) prior preterm birth.

Question 41

During the birth of twins, which represents a maneuver that should not be performed?

A) Artificial rupture of membranes
B) Clamping and cutting of a nuchal cord
C) McRoberts maneuver
D) Breech delivery of the second twin

Answer 41

B) Clamping and cutting of a nuchal cord

it should not be cut, and birth should be attempted with the cord intact.

Question 42

In a complete breech presentation:

A) one or both feet are the presenting part.
B) both hips and knees are flexed, with buttocks presenting.
C) the baby is flexed at the hips.
D) the knees are the presenting part.

Answer 42

B) both hips and knees are flexed, with buttocks presenting.

A complete breech has both hips and knees flexed (like a cannonball dive) and is the most common type of breech presentation.

Question 43

During uterine contractions, intervillous blood flow to the placenta:

A) increases.
B) decreases.
C) remains unchanged.
D) has not been studied in humans.

Answer 43

B) decreases.

During a uterine contraction, the intramyometrial pressure exceeds that of the spiral arteries, resulting in decreased intervillous blood flow.

Question 44

Which of the following statements concerning Apgar scores is correct?

A) Scoring is especially useful in assessment of the preterm infant.
B) Scoring is less useful when the infant is post-term.
C) A score of less than 7 at 1 minute correlates with increased neonatal morbidity.
D) Five-minute scoring has a relationship to neonatal morbidity and mortality.

Answer 44

D) Five-minute scoring has a relationship to neonatal morbidity and mortality.

The 5-minute Apgar score is more predictive of neonatal morbidity and/or mortality than is the 1-minute score.

Question 45

A sudden bradycardia seen in the second stage of labor after an uneventful labor course and previously normal fetal heart tracing is commonly caused by:

A) a vagal response in the fetus related to descent.
B) fetal hypoxia related to length of labor.
C) cord prolapse.
D) uteroplacental insufficiency.

Answer 45

A) a vagal response in the fetus related to descent.

Question 46

Which of the following elective vaginal births is no longer recommended?

A) Brow presentation
B) Face presentation
C) Breech presentation
D) Vertex presentation

Answer 46

C) Breech presentation

Vaginal delivery of breech presentations should be reserved only for breeches that present emergently and when birth is essentially inevitable. Brow presentations often convert to vertex as labor advances and the head encounters the pelvic floor.

Question 47

The following is the clinical picture of your client. She is a G1 P0 at 39 weeks with an uncomplicated pregnancy. Her labor started at 4:00 a.m. with regular contractions. She was admitted at 8:00 a.m., when her exam was 2–3 cm/100%/–2 station, vertex, membranes intact.
At 12:00 p.m., her exam was 3–4 cm/100%/–2, intact.
At 4:00 p.m., her exam was 4 cm/100%/–2, intact.
At 7:30 p.m., her exam was 5–6 cm/100%/–1, intact.
At 8:15 p.m., she ruptured membranes, producing light ­meconium-stained fluid.
At 10:00 p.m., her exam was 8 cm/100%/0 station.
At 10:50 p.m., you notice on the fetal monitor strip early decelerations that occur with every contraction. The baseline heart rate is in the 140s with average variability.
You suspect the cause of these decelerations is:

A) maternal hypotension.
B) head compression.
C) uteroplacental insufficiency.
D) fetal distress related to the meconium fluid.

Answer 47

B) head compression.

Early decelerations are due to a vagal response from head compression and are considered benign.

Question 48

Which one of these clients is most at risk for placental abruption?

A) A 19-year-old G2 P0010 in preterm labor at 35 weeks
B) A 28-year-old G1 smoker pregnant with twins with spontaneous rupture of membranes at 37 weeks
C) A 28-year-old G3 P2002 with induced labor at 41 weeks
D) A 41-year-old G1 pregnant who had a low-lying placenta in the first trimester

Answer 48

B) A 28-year-old G1 smoker pregnant with twins with spontaneous rupture of membranes at 37 weeks

Tobacco use is a significant risk factor for placental abruption.

Question 49

A client presents while you are covering labor and delivery. She is a 33-year-old G3 P2002 at term, and in labor with ruptured membranes. Your exam reveals 5 cm/90% effaced/0 station, but you are unable to palpate fontanels or sutures. You suspect that you feel the orbital ridge in the anteroposterior diameter and the chin at 3 o’clock. If this is the case, what is the presentation?

A) ROT
B) LMT
C) RMT
D) ROA

Answer 49

B) LMT

Question 50

Your patient states that she does not want an episiotomy no matter what happens. Your management of this situation is to:

A) discuss the indications for episiotomy and reinforce that you would obtain consent before performing the procedure if necessary.
B) teach her perineal massage antenatally and hope that she will not need an episiotomy.
C) explain to her that skilled midwives never perform episiotomies.
D) explain that because this is her first baby, she will probably need an episiotomy to prevent serious laceration.

Answer 50

A) discuss the indications for episiotomy and reinforce that you would obtain consent before performing the procedure if necessary.

Although episiotomy is no longer a routine procedure, there are specific indications for its use, which should be discussed with the client.

Question 51

While repairing a first-degree laceration, you notice a continual trickle of bright red blood from the vagina. As you continue your repair, the bleeding becomes slightly more brisk. What would be the next step after fundal massage in your management plan?

A) Bimanual compression
B) Administering 20 additional units of oxytocin via the IV
C) Discussion with the consulting physician regarding the management plan
D) Methylergonovine IM if the blood pressure is normotensive

Answer 51

D) Methylergonovine IM if the blood pressure is normotensive

Methylergonovine causes sustained, tetanic uterine contractions but is contraindicated in hypertensive patients. Bimanual compression would be indicated if bleeding is very brisk—for example, like “a fire hose.”

Question 52

The FHR variability is predominantly controlled by the:

A) parasympathetic/sympathetic nervous system.
B) baroreceptors.
C) chemoreceptors.
D) central nervous system.

Answer 52

A) parasympathetic/sympathetic nervous system.

FHR variability is controlled predominantly by the autonomic nervous system (parasympathetic/sympathetic).

Question 53

A client who is a G3 P2002 at 38 weeks presents with regular uterine contractions every 4 to 6 minutes for 60 seconds for the past 8 hours. Her vaginal exam is 2 cm/30%/–2, vertex with intact membranes. She is very uncomfortable with the contractions and declines discharge to home at this time. At this time, the patient is:

A) in transitional labor.
B) in latent labor.
C) in active labor.
D) not in labor.

Answer 53

B) in latent labor.

The latent phase of labor is from onset of labor until cervical dilation reaches 4–6 cm.

Question 54

Engagement occurs when the:

A) fetal head reaches the pelvic floor.
B) widest diameter of the presenting part descends to or below the pelvic inlet.
C) biparietal diameter is just above the pelvic inlet.
D) head is on the perineum.

Answer 54

B) widest diameter of the presenting part descends to or below the pelvic inlet.

The widest diameter of the fetal head is the biparietal diameter. The definition of engagement is when the biparietal diameter has cleared the pelvic inlet. Once the head is engaged, the leading edge of the fetal head is at the level of the ischial spines (0 station).

Question 55

Which of the following represents a risk factor for shoulder dystocia?

A) Advanced maternal age
B) Epidural anesthesia
C) Polyhydramnios
D) Maternal obesity

Answer 55

D) Maternal obesity

Maternal obesity is a risk factor for a macrosomic infant. Such infants are at greater risk for shoulder dystocia.

Question 56

The cardinal movement responsible for the birth of the fetal head in the cephalic presentation is:

A) flexion.
B) restitution.
C) extension.
D) external rotation.

Answer 56

C) extension.

Question 57

The Ritgen maneuver is used to:

A) slow down the descent of the fetal head during birth.
B) control expulsion of the fetal head at the time of birth.
C) avoid lacerations or the need for an episiotomy.
D) assist in the delivery of the fetal head during extension.

Answer 57

D) assist in the delivery of the fetal head during extension.

The Ritgen maneuver can be used to expedite the delivery of the fetal head when necessary.

Question 58

A client who is a G6 P5005 at 39 weeks was admitted to the labor floor nine hours ago. They continue to have the same contraction pattern every 4 minutes for 60 seconds. Their exam is now 3 cm/100%/0, vertex with intact membranes. The FHR remains in the range of 140–159 bpm with audible accelerations. The client is exhausted and is no longer coping well with the contractions and “just wants it over.” What should be the next step in managing this client?

A) discharge home with encouragement and instructions to return when the contractions become closer.
B) contact the consulting physician regarding your plan for oxytocin augmentation.
C) encourage her to continue with her original plan for an unmedicated childbirth.
D) offer medication of morphine 10 mg IM so she can get some sleep and potentially correct this dysfunctional labor pattern.

Answer 58

D) offer medication of morphine 10 mg IM so she can get some sleep and potentially correct this dysfunctional labor pattern.

Morphine is quite effective for maternal exhaustion due to a ­prodromal/prolonged latent phase of labor.

Question 59

A client who is a G6 P5005 at 39 weeks presents with regular uterine contractions that are every 4 minutes for 60 seconds. Their exam is 3 cm/50%/–2, vertex with intact membranes. The FHR is 150 bpm with audible accelerations by Doppler. At this time, your client is in:

A) a prolonged latent phase of labor.
B) the latent phase of labor.
C) the active phase of labor.
D) an unknown phase of labor because you cannot make a determination based on this information.

Answer 59

B) the latent phase of labor.

The latent phase of labor is from onset of labor until cervical dilation reaches 4–6 cm.

Question 60

In a second-degree laceration, which structure is not involved?

A) Vaginal mucosa
B) Deep transverse perineal muscles
C) Rectal sphincter
D) Hymenal ring

Answer 60

C) Rectal sphincter

A second-degree laceration involves the vaginal mucosa, posterior fourchette, perineal muscles, and perineal skin.

Question 61

What complication may be encountered if a placenta is delivered by the Duncan mechanism?

A) Increased perineal lacerations
B) Increased bleeding
C) Increased hemorrhoids due to extra maternal pushing effort
D) Uterine inversion

Answer 61

B) Increased bleeding

Bleeding is more visible and likely to be increased because of incomplete separation of the placenta.

Question 62

Intermittent auscultation of the FHR during labor is:

A) inferior to continuous EFM.
B) acceptable only for out-of-hospital birth.
C) acceptable for the fetal evaluation of certain patients.
D) correlated with lower Apgar scores than for babies born after continuous fetal monitoring.

Answer 62

C) acceptable for the fetal evaluation of certain patients.

Intermittent auscultation is an acceptable method of assessing fetal well-being in low-risk clients.

Question 63

Which of the following represents a risk factor for retained placenta?

A) Preterm delivery
B) Multiple gestation
C) Multiparity
D) Post-term pregnancy

Answer 63

A) Preterm delivery

Question 64

What is the most common position in which the fetus enters the pelvis for birth?

A) ROA
B) LOA
C) ROP
D) LOP

Answer 64

B) LOA

Question 65

Tocolysis of premature labor contractions is most effectively achieved by:

A) NSAIDs.
B) calcium channel blockers such as nifedipine.
C) intravenous fluids.
D) oxytocics.

Answer 65

B) calcium channel blockers such as nifedipine.

Recent research has determined that calcium channel blockers are most effective for tocolysis.

Question 66

The long arc rotation is most commonly performed by babies beginning labor in which presentation?

A) LOP
B) LSA
C) ROA
D) LOA

Answer 66

A) LOP

Most babies who are in posterior position undergo a long arc rotation to an anterior position before birth.

Question 67

Which of the following would not cause an alteration in the variability of the FHR?

A) Medications
B) Congenital cardiac anomalies of the fetus
C) Placenta previa
D) Fetal activity patterns

Answer 67

C) Placenta previa

The other choices—medications, congenital cardiac anomalies, and fetal activity—are known factors that influence FHR variability.

Question 68

During the second stage of labor for the high-risk client, the FHR should be monitored:

A) every 5 minutes.
B) every 15 minutes.
C) every 30 minutes.
D) every 5 minutes or continuously.

Answer 68

D) every 5 minutes or continuously.

Every 5 minutes or continuously are acceptable for the frequency for auscultation in the second stage, per ACOG’s recommendations for the high-risk client.

Question 69

Hemodynamic changes during the initial postpartum period include:

A) elevated cardiac output for as long as 48 hours after the birth.
B) decreased white blood count (WBC) during the first 72 hours after the birth.
C) elevated blood pressure for 48 hours after the birth.
D) decreased urine output for the first 24 hours after the birth.

Answer 69

A) elevated cardiac output for as long as 48 hours after the birth.

Within the first hours postdelivery, cardiac output increases 60% to 80%.

Question 70

A client who is a G6 P5005 at 39 weeks was admitted to the labor floor 9 hours ago. They continue to have the same contraction pattern every 4 minutes for 60 seconds. Their exam is now 3 cm/100%/0, vertex with intact membranes. The FHR remains in the range of 140–159 bpm with audible accelerations. The client is exhausted and is no longer coping well with the contractions and “just wants it over.” Your diagnosis at this time is that she is in:

A) the latent phase of labor.
B) a prolonged latent phase of labor.
C) arrested labor.
D) a protracted active phase of labor.

Answer 70

B) a prolonged latent phase of labor.

The client is exhausted from the abnormal latent phase.

Question 71

A client who is at 41 weeks and 6 days’ gestation is in labor, at 4 cm/100%/+1, vertex, and she is having contractions every 3 to 5 minutes for 50–70 seconds, which are moderate to palpation. The FHR baseline is still in the 140s, but she is having variable decelerations to the 110s with good return to baseline and average variability. What action would be contraindicated at this time?

A) Allow the patient to get into the Jacuzzi.
B) Begin oxytocin augmentation.
C) Insert an intravenous catheter.
D) Provide expectant management.

Answer 71

A) Allow the patient to get into the Jacuzzi.

Variable decelerations are an indication for continuous monitoring, which cannot be accomplished in the Jacuzzi.

Question 72

Which of the following FHR tracings are indicative of a Category III FHR tracing?

A) A prolonged deceleration with recovery to baseline and with moderate variability
B) Variable decelerations that become more pronounced during the second stage but with normal FHR between pushing efforts
C) Late decelerations and an absence of variability
D) Late decelerations with return to baseline and moderate variability between decelerations

Answer 72

C) Late decelerations and an absence of variability

Question 73

The following is the clinical picture of your client. She is a G1 P0 at 39 weeks with an uncomplicated pregnancy. Her labor started at 4:00 a.m. with regular contractions. She was admitted at 8:00 a.m., when her exam was 2–3 cm/100%/–2 station, vertex, membranes intact. At 12:00 p.m., her exam was 3–4 cm/100%/–2, intact. At 4:00 p.m., her exam was 4 cm/100%/–2, intact. At 7:30 p.m., her exam was 5–6 cm/100%/–1, intact. At 8:15 p.m., she ruptured membranes, producing light ­meconium-stained fluid. At 10:00 p.m., her exam was 8 cm/100%/0 station. What was the most appropriate diagnosis at 7:30 p.m.?

A) Unable to make determination based on the information provided
B) Active phase of labor
C) Latent phase of labor
D) Arrest of labor in the active phase

Answer 73

B) Active phase of labor

The active phase of labor is from cervical dilation of 4–6 cm until complete dilation.

Question 74

At 38 weeks’ gestation, Ms. Jones presents to your birth center complaining of a small amount of watery, clear-to-whitish vaginal discharge for the past 8 hours. She has been having Braxton Hicks contractions for a couple of days. The baby is moving on a regular basis, but now she just “does not feel right.” What would you do in your initial assessment related to her presenting symptoms?

A) Obtain a 20-minute fetal monitor strip to ensure reactivity.
B) Perform a sterile speculum exam to rule out rupture of membranes versus vaginal infection.
C) Contact the consulting physician regarding the premature rupture of membranes protocol.
D) Send Ms. Jones home with reassurance and instructions to rest until a better labor pattern is established.

Answer 74

B) Perform a sterile speculum exam to rule out rupture of membranes versus vaginal infection.

Question 75

Which of the following conditions would not necessitate continuous fetal monitoring?

A) Labor at 41 weeks and 1 day
B) Thick, meconium-stained fluid
C) Nonreactive nonstress test (NST) and now in labor
D) IV narcotics

Answer 75

A) Labor at 41 weeks and 1 day

Forty-one weeks and 1 day is normal gestation (i.e., not preterm or postdates). The other choices—thick, meconium-stained fluid; NST; and IV narcotics—entail risk factors that would necessitate continuous fetal monitoring.