NCLEX Labor and Delivery Questions

The stages of labour and what to assess in each

The first stage runs from the onset of true labour to full dilation at 10 centimetres and is divided into latent, active and transition phases. The latent phase is 0 to 5 centimetres with mild irregular contractions and a talkative, sociable mother. The active phase is roughly 6 to 8 centimetres with stronger, more regular contractions and increasing focus. Transition, from 8 to 10 centimetres, is the shortest and most intense, with irritability, nausea, trembling and a sense of loss of control being expected rather than abnormal.

The second stage runs from full dilation to birth and involves pushing with the urge to bear down. The third stage runs from birth of the baby to delivery of the placenta, usually within 30 minutes, with signs of separation being a gush of blood, lengthening of the cord and a globular uterus. The fourth stage is the first one to four hours after delivery, when haemorrhage risk is highest and fundal, lochia and vital sign assessments are performed frequently.

Distinguishing true from false labour is a recurring item. True labour produces regular contractions that increase in frequency, duration and intensity, are not relieved by rest or walking, cause cervical change, and produce discomfort that begins in the back and radiates forward. False labour, or Braxton Hicks, is irregular, does not intensify, often eases with position change or hydration, and produces no cervical change.

Ruptured membranes require immediate assessment of the fetal heart rate to detect cord prolapse, then documentation of the time, amount, colour and odour of the fluid. Green fluid indicates meconium; foul-smelling or cloudy fluid suggests infection; and prolonged rupture beyond 24 hours increases infection risk.

• •First stage: onset to 10 cm, three phases
• •Second stage: full dilation to birth
• •Third stage: birth to placental delivery
• •Fourth stage: first 1–4 hours, highest haemorrhage risk
• •After rupture of membranes, check the fetal heart rate first

Fetal monitoring: decelerations and intrauterine resuscitation

The mnemonic VEAL CHOP is worth committing to memory because it converts a monitoring strip into an action. Variable decelerations are caused by cord compression, early decelerations by head compression, accelerations are okay and reassuring, and late decelerations are caused by placental insufficiency. Baseline fetal heart rate is 110 to 160 beats per minute, and moderate variability of 6 to 25 beats is the single most reassuring feature of a strip.

Early decelerations mirror the contraction, beginning and ending with it, and require no intervention beyond continued monitoring. Variable decelerations are abrupt, V-shaped and unrelated to the timing of contractions, and the first action is to reposition the mother to relieve cord compression, then apply oxygen and consider amnioinfusion if ordered.

Late decelerations begin after the peak of the contraction and return to baseline after it ends, and they signal uteroplacental insufficiency. The intervention set must be memorised as a sequence: stop oxytocin, reposition the mother to the left lateral side, administer oxygen at 8 to 10 litres per minute by non-rebreather mask, increase the intravenous fluid rate, and notify the provider. Minimal or absent variability with recurrent late decelerations is a category III strip requiring urgent delivery preparation.

Oxytocin safety appears alongside monitoring. Tachysystole is more than five contractions in ten minutes averaged over 30 minutes, or contractions lasting longer than 90 seconds with less than 60 seconds of rest between them. Either finding, or a non-reassuring fetal heart rate, means stop the infusion immediately, and terbutaline may be ordered as a uterine relaxant.

Intrapartum emergencies and comfort measures

Umbilical cord prolapse is the emergency most likely to appear. The nurse's gloved hand goes into the vagina to lift the presenting part off the cord and stays there, the mother is placed in knee-chest or Trendelenburg position, oxygen is applied, help is called and preparation for immediate caesarean birth begins. The cord is never pushed back in, and if visible outside the body it is kept moist with sterile saline gauze.

Placental abruption presents with sudden painful vaginal bleeding and a rigid, board-like tender uterus; placenta previa presents with painless bright red bleeding and a soft uterus, and vaginal examination is contraindicated. Uterine rupture presents with sudden severe pain, cessation of contractions and loss of fetal station. Amniotic fluid embolism presents with abrupt respiratory distress, cyanosis and cardiovascular collapse.

Postpartum haemorrhage is defined as blood loss exceeding 500 mL after vaginal birth or 1,000 mL after caesarean. The first action for a boggy uterus is fundal massage, followed by emptying the bladder because a full bladder displaces the uterus and prevents contraction, then administering uterotonics such as oxytocin, methylergonovine, which is contraindicated in hypertension, or carboprost, which is cautioned in asthma.

Comfort measures and epidural care matter too. Before an epidural, give a fluid bolus to reduce the risk of maternal hypotension, and afterwards monitor blood pressure frequently, watch for hypotension treated by left lateral positioning, fluids and possibly ephedrine, and monitor bladder distension because sensation is reduced. Review our maternity guide and postpartum article, then practise with the maternal and newborn question sets.

• •Cord prolapse: lift the presenting part and keep your hand in place
• •Abruption: painful bleeding, rigid uterus; previa: painless bleeding, no vaginal exam
• •Boggy uterus: massage first, then empty the bladder
• •Methylergonovine is contraindicated in hypertension
• •Pre-epidural fluid bolus prevents maternal hypotension