HIGH RISK INTRAPARTUM EXAM 2 NCLEX QUESTIONS
WITH CORRECT ANSWERS.
1) A client has been diagnosed with water intoxication after having received IV
_ _ _ _ _ _ _ _ _ _ _ _
oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would
_ _ _ _ _ _ _ _ _ _ _ _
the nurse expect to see?
_ _ _ _
1. Confusion, drowsiness, and vomiting. _ _ _ _
2. Hypernatremia and hyperkalemia. _ _ _
3. Thrombocytopenia and neutropenia. _ _ _
4. Paresthesias, myalgias, and anemia. -- Correct Answer ✔✔ 1 _ _ _ _ _ _ _ _
2) The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which
_ _ _ _ _ _ _ _ _ _ _ _ _
of the following situations should the nurse refuse to comply with the order?
_ _ _ _ _ _ _ _ _ _ _ _ _
1. Primigravida with a transverse lie. _ _ _ _ _
2. Multigravida with cerebral palsy. _ _ _ _
3. Primigravida who is 14 years old. _ _ _ _ _ _
4. Multigravida who has type 1 diabetes. -- Correct Answer ✔✔ 1 _ _ _ _ _ _ _ _ _ _
3) A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for
_ _ _ _ _ _ _ _ _ _ _ _ _
hypertension and oligohydramnios. She is contracting q 3 min × 60 to 90 seconds.
_ _ _ _ _ _ _ _ _ _ _ _ _ _
She suddenly complains of abdominal pain accompanied by significant fetal heart
_ _ _ _ _ _ _ _ _ _ _
bradycardia. Which of the following interventions should the nurse perform first?
_ _ _ _ _ _ _ _ _ _
1. Turn off the oxytocin infusion.
_ _ _ _ _
2. Administer oxygen via face mask. _ _ _ _ _
3. Reposition the patient. _ _ _
4. Call the obstetrician. -- Correct Answer ✔✔ 1
_ _ _ _ _ _ _
,4) An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
rate of 0.5 milliunits per minute. The woman's primary physician orders: Increase
_ _ _ _ _ _ _ _ _ _ _ _
the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions
_ _ _ _ _ _ _ _ _ _ _ _ _
are every 3 minutes × 60 seconds. The nurse refuses to comply with the order.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Which of the following is the rationale for the nurse's action?
_ _ _ _ _ _ _ _ _ _ _
1. Fetal distress has been noted in labors when oxytocin dosages greater than 2
_ _ _ _ _ _ _ _ _ _ _ _ _
milliunits per minute are administered. _ _ _ _ _
2. The relatively long half-life of oxytocin can result in unsafe intravascular
_ _ _ _ _ _ _ _ _ _ _
concentrations of the drug. _ _ _ _
3. It is unsafe practice to administer oxytocin intravenously to a woman who is
_ _ _ _ _ _ _ _ _ _ _ _ _
carrying a postdates fetus. _ _ _ _
4. A contraction duration of 60 seconds can lead to fetal compromise in a baby
_ _ _ _ _ _ _ _ _ _ _ _ _ _
that is postmature. -- Correct Answer ✔✔ 2
_ _ _ _ _ _ _
5) A 40-week-gestation woman has received Cytotec (misoprostol) for cervical
_ _ _ _ _ _ _ _ _
ripening. For which of the following signs/symptoms should the nurse carefully
_ _ _ _ _ _ _ _ _ _ _
monitor the client? _ _ _
1. Diarrhea and back pain. _ _ _ _
2. Hypothermia and rectal pressure. _ _ _ _
3. Urinary retention and rash. _ _ _ _
4. Tinnitus and respiratory distress. -- Correct Answer ✔✔ 1 _ _ _ _ _ _ _ _
6) A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min.
_ _ _ _ _ _ _ _ _ _ _ _ _ _
Her current contraction pattern is every 3 minutes × 45 seconds with moderate
_ _ _ _ _ _ _ _ _ _ _ _ _
intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
the following interventions should the nurse take at this time?
_ _ _ _ _ _ _ _ _ _
1. Stop her infusion. _ _ _
2. Give her oxygen. _ _ _
3. Change her position. _ _ _
4. Monitor her labor. -- Correct Answer ✔✔ 4 _ _ _ _ _ _ _
7) A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse
_ _ _ _ _ _ _ _ _ _ _ _ _
should be prepared to administer the medication via which of the following routes?
_ _ _ _ _ _ _ _ _ _ _ _ _
, 1. Intravenously. _
2. Orally. _
3. Endocervically. _
4. Intrathecally. -- Correct Answer ✔✔ 3 _ _ _ _ _
8) The nurse turns off the oxytocin (Pitocin) infusion after a period of
_ _ _ _ _ _ _ _ _ _ _ _
hyperstimulation. Which of the following outcomes indicates that the nurse's action
_ _ _ _ _ _ _ _ _ _ _
was effective?
_ _
1. Intensity moderate. _ _
2. Frequency every 3 minutes. _ _ _ _
3. Duration 130 seconds. _ _ _
4. Attitude flexed. -- Correct Answer ✔✔ 2
_ _ _ _ _ _
9) A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_mL per hour. Which of the following clinical signs would lead the nurse to stop the
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
infusion? _
1. Change in maternal pulse rate from 76 to 98 bpm.
_ _ _ _ _ _ _ _ _ _
2. Change in fetal heart rate from 128 to 102 bpm.
_ _ _ _ _ _ _ _ _ _
3. Maternal blood pressure of 150/100. _ _ _ _ _
4. Maternal temperature of 102.4°F -- Correct Answer ✔✔ 2
_ _ _ _ _ _ _ _
10) A primigravid client received Cervidil (dinoprostone) for induction 8 hours ago. The
_ _ _ _ _ _ _ _ _ _ _
_Bishop score is now 10. Which of the following actions by the nurse is appropriate?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
1. Perform nitrazine analysis of amniotic fluid.
_ _ _ _ _ _
2. Report abnormal findings to the obstetrician.
_ _ _ _ _ _
3. Place woman on her side.
_ _ _ _ _
4. Monitor for onset of labor. -- Correct Answer ✔✔ 4
_ _ _ _ _ _ _ _ _
11) The physician has ordered Prepidil (dinoprostone) for four gravidas at term. The
_ _ _ _ _ _ _ _ _ _ _ _
nurse should question the order for which of the women?
_ _ _ _ _ _ _ _ _ _
1. Primigravida with Bishop score of 4. _ _ _ _ _ _
2. Multigravida with late decelerations. _ _ _ _
WITH CORRECT ANSWERS.
1) A client has been diagnosed with water intoxication after having received IV
_ _ _ _ _ _ _ _ _ _ _ _
oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would
_ _ _ _ _ _ _ _ _ _ _ _
the nurse expect to see?
_ _ _ _
1. Confusion, drowsiness, and vomiting. _ _ _ _
2. Hypernatremia and hyperkalemia. _ _ _
3. Thrombocytopenia and neutropenia. _ _ _
4. Paresthesias, myalgias, and anemia. -- Correct Answer ✔✔ 1 _ _ _ _ _ _ _ _
2) The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which
_ _ _ _ _ _ _ _ _ _ _ _ _
of the following situations should the nurse refuse to comply with the order?
_ _ _ _ _ _ _ _ _ _ _ _ _
1. Primigravida with a transverse lie. _ _ _ _ _
2. Multigravida with cerebral palsy. _ _ _ _
3. Primigravida who is 14 years old. _ _ _ _ _ _
4. Multigravida who has type 1 diabetes. -- Correct Answer ✔✔ 1 _ _ _ _ _ _ _ _ _ _
3) A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for
_ _ _ _ _ _ _ _ _ _ _ _ _
hypertension and oligohydramnios. She is contracting q 3 min × 60 to 90 seconds.
_ _ _ _ _ _ _ _ _ _ _ _ _ _
She suddenly complains of abdominal pain accompanied by significant fetal heart
_ _ _ _ _ _ _ _ _ _ _
bradycardia. Which of the following interventions should the nurse perform first?
_ _ _ _ _ _ _ _ _ _
1. Turn off the oxytocin infusion.
_ _ _ _ _
2. Administer oxygen via face mask. _ _ _ _ _
3. Reposition the patient. _ _ _
4. Call the obstetrician. -- Correct Answer ✔✔ 1
_ _ _ _ _ _ _
,4) An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
rate of 0.5 milliunits per minute. The woman's primary physician orders: Increase
_ _ _ _ _ _ _ _ _ _ _ _
the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions
_ _ _ _ _ _ _ _ _ _ _ _ _
are every 3 minutes × 60 seconds. The nurse refuses to comply with the order.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Which of the following is the rationale for the nurse's action?
_ _ _ _ _ _ _ _ _ _ _
1. Fetal distress has been noted in labors when oxytocin dosages greater than 2
_ _ _ _ _ _ _ _ _ _ _ _ _
milliunits per minute are administered. _ _ _ _ _
2. The relatively long half-life of oxytocin can result in unsafe intravascular
_ _ _ _ _ _ _ _ _ _ _
concentrations of the drug. _ _ _ _
3. It is unsafe practice to administer oxytocin intravenously to a woman who is
_ _ _ _ _ _ _ _ _ _ _ _ _
carrying a postdates fetus. _ _ _ _
4. A contraction duration of 60 seconds can lead to fetal compromise in a baby
_ _ _ _ _ _ _ _ _ _ _ _ _ _
that is postmature. -- Correct Answer ✔✔ 2
_ _ _ _ _ _ _
5) A 40-week-gestation woman has received Cytotec (misoprostol) for cervical
_ _ _ _ _ _ _ _ _
ripening. For which of the following signs/symptoms should the nurse carefully
_ _ _ _ _ _ _ _ _ _ _
monitor the client? _ _ _
1. Diarrhea and back pain. _ _ _ _
2. Hypothermia and rectal pressure. _ _ _ _
3. Urinary retention and rash. _ _ _ _
4. Tinnitus and respiratory distress. -- Correct Answer ✔✔ 1 _ _ _ _ _ _ _ _
6) A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min.
_ _ _ _ _ _ _ _ _ _ _ _ _ _
Her current contraction pattern is every 3 minutes × 45 seconds with moderate
_ _ _ _ _ _ _ _ _ _ _ _ _
intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
the following interventions should the nurse take at this time?
_ _ _ _ _ _ _ _ _ _
1. Stop her infusion. _ _ _
2. Give her oxygen. _ _ _
3. Change her position. _ _ _
4. Monitor her labor. -- Correct Answer ✔✔ 4 _ _ _ _ _ _ _
7) A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse
_ _ _ _ _ _ _ _ _ _ _ _ _
should be prepared to administer the medication via which of the following routes?
_ _ _ _ _ _ _ _ _ _ _ _ _
, 1. Intravenously. _
2. Orally. _
3. Endocervically. _
4. Intrathecally. -- Correct Answer ✔✔ 3 _ _ _ _ _
8) The nurse turns off the oxytocin (Pitocin) infusion after a period of
_ _ _ _ _ _ _ _ _ _ _ _
hyperstimulation. Which of the following outcomes indicates that the nurse's action
_ _ _ _ _ _ _ _ _ _ _
was effective?
_ _
1. Intensity moderate. _ _
2. Frequency every 3 minutes. _ _ _ _
3. Duration 130 seconds. _ _ _
4. Attitude flexed. -- Correct Answer ✔✔ 2
_ _ _ _ _ _
9) A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_mL per hour. Which of the following clinical signs would lead the nurse to stop the
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
infusion? _
1. Change in maternal pulse rate from 76 to 98 bpm.
_ _ _ _ _ _ _ _ _ _
2. Change in fetal heart rate from 128 to 102 bpm.
_ _ _ _ _ _ _ _ _ _
3. Maternal blood pressure of 150/100. _ _ _ _ _
4. Maternal temperature of 102.4°F -- Correct Answer ✔✔ 2
_ _ _ _ _ _ _ _
10) A primigravid client received Cervidil (dinoprostone) for induction 8 hours ago. The
_ _ _ _ _ _ _ _ _ _ _
_Bishop score is now 10. Which of the following actions by the nurse is appropriate?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
1. Perform nitrazine analysis of amniotic fluid.
_ _ _ _ _ _
2. Report abnormal findings to the obstetrician.
_ _ _ _ _ _
3. Place woman on her side.
_ _ _ _ _
4. Monitor for onset of labor. -- Correct Answer ✔✔ 4
_ _ _ _ _ _ _ _ _
11) The physician has ordered Prepidil (dinoprostone) for four gravidas at term. The
_ _ _ _ _ _ _ _ _ _ _ _
nurse should question the order for which of the women?
_ _ _ _ _ _ _ _ _ _
1. Primigravida with Bishop score of 4. _ _ _ _ _ _
2. Multigravida with late decelerations. _ _ _ _
