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HESI RN · HESI Maternity · 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 nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?

A. Fetal head is felt at 0 station during the vaginal examination.

B. Bloody mucous discharge increases.

C. Vulva bulges and encircles the fetal head.

D. Membranes rupture during a contraction.

Expert Explanatory Rationale

Correct Answer: Vulva bulges and encircles the fetal head.

Question 2 of 5

A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with

A. more rapid labor.

B. a high risk of infection.

C. maternal perineal traum

D. umbilical cord compression.

Expert Explanatory Rationale

Correct Answer: umbilical cord compression.

Question 3 of 5

A 29-year-old gravida 1, para 0 woman who is 35 weeks pregnant is admitted to the labor and delivery unit. She states that there is fluid leaking from her vagina but she is not sure if it is urine. What should the nurse do to make the determination?

A. A nitrazine test is the most conclusive test.

B. Nitrazine paper changes from yellow to dark blue due to the acidic nature of amniotic fluid.

C. Ferning is more conclusive than nitrazine paper testing.

D. Note if there is fluid leaking from the perineal area.

Expert Explanatory Rationale

Correct Answer: A nitrazine test is the most conclusive test.

Question 4 of 5

An infant was born 1 minute ago and the Apgar score is being assigned. The infant has blue extremities, minimal flexion, a weak cry, a heart rate of 110 beats per minute, and coughs and pulls away when suctioned. How many points should be assigned? Record your answer using a whole number:

A. 3

B. 2

C. 1

Expert Explanatory Rationale

Correct Answer: 3

Question 5 of 5

Bloody show differs from active vaginal bleeding in that bloody show:

A. Quickly clots on the perineal pad.

B. Is dark red and mixed with mucus.

C. Flows freely during vaginal examination.

D. Decreases in quantity as labor progresses.

Expert Explanatory Rationale

Correct Answer: Is dark red and mixed with mucus.

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