OB HESI RN 2024/2025 EXAM
QUESTIONS AND ANSWERS
A diabetic client delivers a full-term large-for-gestational-age infant who is jittery. What
action should the nurse take first?
a. Obtain a blood glucose level
b. Administer oxygen
c. Feed the infant glucose water
d. Decrease environmental stimuli - Answer-a. Obtain a blood glucose level
A 30-year-old primp delivers a 9 lb infant vaginally after a 30-hour labor. What is the
priority nursing action for this client?
a. Observe for signs of uterine hemorrhage
b. Encourage direct contact with the infant
c. Assess the blood pressure for hypertension
d. Gently massage fundus every 4 hours - Answer-a. Observe for signs of uterine
hemorrhage
A term multip, who is receiving oxytocin for labor augmentation, is requesting pain
medication. Review of the client's record indicates that she was medicated 30 minutes
ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push.
Vaginal examination reveals that the client's cervical dilation is 3 cm, 70% effaced, and
at a 0 station. What action should the nurse implement?
a. Medicate the client with an additional 1 mg of Stadol IV push
b. Instruct the client to use deep breathing during a contraction
c. Discontinue the Pitocin infusion
d. Notify the HCP - Answer-b. Instruct the client to use deep breathing during a
contraction
A multiparous client at 38-weeks gestation is admitted to labor and delivery with a
complaint of contractions 5 minutes apart. While the client is in the bathroom changing
into a hospital gown, the nurse hears a baby crying. What action should the nurse take
first?
a. Inspect the client's perineum
b. Turn on the infant warmer
c. Notify the hcp
d. Push the call light for help - Answer-d. Push the call light for help
A client who is receiving oxytocin to augment early labor begins to experience hyper
systolic or tetanic contractions with variable fetal heart decelerations. Which action
should the nurse implement?
a. Reposition the fetal monitor transducers
b. Alert the charge nurse to the patient's condition
c. Turn off the Pitocin infusion
, d. Decrease the rate of the Pitocin infusion - Answer-c. Turn off the Pitocin infusion
The nurse is assessing a newborn who was precipitously delivered at 38-weeks
gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment
action is most important for the nurse to implement?
A. Determine reactivity of neonatal reflexes
b. Perform gestational age assessment
c. Weigh and measure the newborn
d. Obtain a drug screen for cocaine - Answer-d. Obtain a drug screen for cocaine
A newborn infant is receiving positive pressure ventilation after delivery. Based on
which assessment finding should the nurse initiate chest compression?
a. Apgar score 7
b. Heart rate 54
c. Limp muscle tone
d. Central cyanosis - Answer-b. Heart rate 54
Vaginal prostaglandin gel is used to induce labor for a woman who is at 42-weeks
gestation. Thirty minutes after insertion of the gel, the client complains of vaginal
warmth, and is experiencing 90 second contractions with fetal heart rate decelerations.
What action should the nurse implement first?
a. Notify the HCP
b. Assess the maternal vital signs
c. Turn to a side-lying position
d. Increase the IV infusion rate - Answer-c. Turn to a side-lying position
A woman who delivered a normal newborn 24 hours ago complains, "I seem to be
urinating every hour or so. Is that OK?" Which action should the nurse implement?
a. Catheterize the client for residual urine volume
b. Measure the next voiding, the palpate the client's bladder
c. Evaluate for normal involution, then massage the fundus
d. Obtain a specimen for urine culture and sensitivity - Answer-b. Measure the next
voiding, the palpate the client's bladder
3. A client whose labor is being augmented with oxytocin infusion requests an epidural
for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm
cervical dilation, 60% effacement, and -2 station. What action should the nurse
implement first?
a. Give a bolus of intravenous fluids
b. Request placement of the epidural
c. Determine current cervical dilation
d. Decrease the oxytocin infusion rate - Answer-c. Determine current cervical dilation
3. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client
who had an epidural and notes a large amount of lochia on the perineal pad. The nurse
QUESTIONS AND ANSWERS
A diabetic client delivers a full-term large-for-gestational-age infant who is jittery. What
action should the nurse take first?
a. Obtain a blood glucose level
b. Administer oxygen
c. Feed the infant glucose water
d. Decrease environmental stimuli - Answer-a. Obtain a blood glucose level
A 30-year-old primp delivers a 9 lb infant vaginally after a 30-hour labor. What is the
priority nursing action for this client?
a. Observe for signs of uterine hemorrhage
b. Encourage direct contact with the infant
c. Assess the blood pressure for hypertension
d. Gently massage fundus every 4 hours - Answer-a. Observe for signs of uterine
hemorrhage
A term multip, who is receiving oxytocin for labor augmentation, is requesting pain
medication. Review of the client's record indicates that she was medicated 30 minutes
ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push.
Vaginal examination reveals that the client's cervical dilation is 3 cm, 70% effaced, and
at a 0 station. What action should the nurse implement?
a. Medicate the client with an additional 1 mg of Stadol IV push
b. Instruct the client to use deep breathing during a contraction
c. Discontinue the Pitocin infusion
d. Notify the HCP - Answer-b. Instruct the client to use deep breathing during a
contraction
A multiparous client at 38-weeks gestation is admitted to labor and delivery with a
complaint of contractions 5 minutes apart. While the client is in the bathroom changing
into a hospital gown, the nurse hears a baby crying. What action should the nurse take
first?
a. Inspect the client's perineum
b. Turn on the infant warmer
c. Notify the hcp
d. Push the call light for help - Answer-d. Push the call light for help
A client who is receiving oxytocin to augment early labor begins to experience hyper
systolic or tetanic contractions with variable fetal heart decelerations. Which action
should the nurse implement?
a. Reposition the fetal monitor transducers
b. Alert the charge nurse to the patient's condition
c. Turn off the Pitocin infusion
, d. Decrease the rate of the Pitocin infusion - Answer-c. Turn off the Pitocin infusion
The nurse is assessing a newborn who was precipitously delivered at 38-weeks
gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment
action is most important for the nurse to implement?
A. Determine reactivity of neonatal reflexes
b. Perform gestational age assessment
c. Weigh and measure the newborn
d. Obtain a drug screen for cocaine - Answer-d. Obtain a drug screen for cocaine
A newborn infant is receiving positive pressure ventilation after delivery. Based on
which assessment finding should the nurse initiate chest compression?
a. Apgar score 7
b. Heart rate 54
c. Limp muscle tone
d. Central cyanosis - Answer-b. Heart rate 54
Vaginal prostaglandin gel is used to induce labor for a woman who is at 42-weeks
gestation. Thirty minutes after insertion of the gel, the client complains of vaginal
warmth, and is experiencing 90 second contractions with fetal heart rate decelerations.
What action should the nurse implement first?
a. Notify the HCP
b. Assess the maternal vital signs
c. Turn to a side-lying position
d. Increase the IV infusion rate - Answer-c. Turn to a side-lying position
A woman who delivered a normal newborn 24 hours ago complains, "I seem to be
urinating every hour or so. Is that OK?" Which action should the nurse implement?
a. Catheterize the client for residual urine volume
b. Measure the next voiding, the palpate the client's bladder
c. Evaluate for normal involution, then massage the fundus
d. Obtain a specimen for urine culture and sensitivity - Answer-b. Measure the next
voiding, the palpate the client's bladder
3. A client whose labor is being augmented with oxytocin infusion requests an epidural
for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm
cervical dilation, 60% effacement, and -2 station. What action should the nurse
implement first?
a. Give a bolus of intravenous fluids
b. Request placement of the epidural
c. Determine current cervical dilation
d. Decrease the oxytocin infusion rate - Answer-c. Determine current cervical dilation
3. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client
who had an epidural and notes a large amount of lochia on the perineal pad. The nurse
