Answers 2023
1. Pregnant patient, with contractions that are 5 min apart, goes to the
bathroom and you hear a baby crying. What is the best action for the
nurse to do? -
✔hit the call light to call for help
2. Post partal patient has a spinal headache 24 hours after
delivery. Prior to anesthesiologist's arrival what action is best for
the nurse to perform? -
✔have equipment at bedside
3. Patient 20 weeks gestation has HPV. What is the best information for
the nurse to provide? -
✔treatment is available but limited due to pregnancy
4. One hour after delivery the nurse is unable to palpate the fundus. Large
amount of lochia on pad. Massage umbilicus and get vitals. What
intervention does the nurse implement next? -
✔palpate for bladder distention
5. Infant with cephalatoma. What action should the nurse do next? -
✔assess for jaundice q 8 hours
6. Math problem - Pitocin 4 mU/min. 1000 mL/2 mU. mL/hr -
✔12 mL/hr
7. Patient receiving Pitocin is experiencing tetanic contractions with variable
FHR. What action should the nurse implement? -
✔- turn off the Pitocin drip
8. Patient scheduled for cesarean for 0600 tells the nurse that she drank
some coffee at 0400 to avoid getting a headache. What action does the
nurse take next? -
✔tell the anesthesiologist
, 9. After delivery of a 10 pound baby 2 hours ago, the fundus is above and to
the right of the umbilicus. She voids 250 mL in a bed pan, Action to
implement? -
✔palpate suprapubic region for distention
10.33 weeks gestation. Moderate bleeding. No contractions. What
intervention to implement? -
✔Weigh pads
11.Primipara 42 weeks gestation. Pitocin started then stopped.
O2 applied. Contractions 5 minutes apart for 20 seconds.
Intervention to implement? -
✔restart Pitocin per protocol
12.Patient with continuous fetal monitoring notices FHR fall and rise
abruptly with "v" shaped pattern. Nurse action to take first? -
✔change position of patient
13.28 weeks gestation with twins. Fundal height 27 cm. fundal height
measured 28 cm 3 weeks ago. What does the nurse conclude from this? -
✔may indicate IUGR
14.Patient received prostaglandin gel vaginally to induce labor. 30
minutes after insertion of gel, patient complains of vaginal warmth.
What action should nurse implement first? -
✔turn patient to a side lying position
15.Parents tell nurse that baby is trying to walk. Nurse's response? -
✔explain it is a normal stepping reflex
16.Patient delivered baby 24 hours ago and complains of urinating every
hour or so. She asks the nurse "is that ok?" Nurse's action? -
✔measure next voiding
17.Magnesium sulfate infusion begins. Patient develops slurred speech and
decreased reflexes. What nurse action to implement? -
✔stop the infusion