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HESI LPN · HESI LPN Maternal Newborn · HESI high risk labor and delivery nclex questions

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

Which physiologic event is the key indicator of the commencement of true labor?

A. Bloody show

B. Cervical dilation and effacement

C. Fetal descent into the pelvic inlet

D. Uterine contractions every 7 minutes

Expert Explanatory Rationale

Correct Answer: Cervical dilation and effacement

Question 2 of 5

The nurse is caring for a laboring patient with multiple family members in the room. How can the nurse address this situation?

A. Educate the family that the pain the laboring person is experiencing is normal.

B. Ask them all to leave the room.

C. Explain that if the laboring person got an epidural, she would be more comfortable

D. Assume the laboring person wants the family in the room

Expert Explanatory Rationale

Correct Answer: Ask them all to leave the room.

Question 3 of 5

A 40-year-old G2, P1 woman is admitted to the labor and delivery unit with contractions 6 minutes apart. She is 36 weeks pregnant, has a history of placenta previa, and is currently experiencing moderate vaginal bleeding. What should the nurse be prepared to do?

A. Perform a vaginal examination to determine cervical dilation

B. Assist the health care provider to perform artificial rupture of the membranes

C. Initiate external fetal monitoring

D. Encourage patient to ambulate to intensify labor

Expert Explanatory Rationale

Correct Answer: Initiate external fetal monitoring

Question 4 of 5

How should the nurse respect the rapid psychologic changes occurring in the fourth stage of labor?

A. Invite the family to come in and see the newborn.

B. Take the lead from the parents regarding interruption of the bonding.

C. Ask multiple questions about taking pictures of the newborn.

D. Take the newborn to the nursery to encourage the parents to rest.

Expert Explanatory Rationale

Correct Answer: Take the lead from the parents regarding interruption of the bonding.

Question 5 of 5

A gravida 2, para 1 is in active labor at 39 weeks gestation. Her cervical exam is 6 cm dilated, 60% effaced, and 0 station. An amniotomy is performed by the physician. The fluid is noted to be bloody and the fetal heart tones have decelerated to the 50s. What is the nurseÃ¢â‚¬â„¢s next best action?

A. Notify the operating team of emergent cesarean delivery

B. Assist the patient to left lateral position

C. Apply O2 at 10-12 L/min per nonrebreather

D. Administer an IV fluid bolus

Expert Explanatory Rationale

Correct Answer: Notify the operating team of emergent cesarean delivery

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