HESI RN Maternity Quiz Bank with Complete Solutions| Questions and Verified Answers| 2023-2024
QUESTION
One hour after giving birth to an 8-pound infa... [Show More] nt, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine
0.2 mg IM x 1. What action should the nurse take immediately?
a. Give the medication as prescribed and monitor for efficacy
b. Encourage the client to breastfeed rather than bottle feed
c. Have the client empty her bladder and massage the fundus
d. Call the healthcare provider to question the prescription
Answer:
d. Call the healthcare provider to question the prescription
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription (D).
QUESTION
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is:
a. shortness of breath
b. joint pain
c. a persistent cold
d. organomegaly
Answer:
c. a persistent cold
Respiratory tract infections commonly occur in the pediatric population. However, the child with AIDS has a decreased ability to defend the body against these infections and often the presenting symptom of a child with AIDS is a persistent cold (C).
QUESTION
A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply)
a. Dark, red vaginal bleeding
b. Lower back pain
c. Premature rupture of membranes
d. Increased uterine irritability
e. Bilateral pitting edema
f. A rigid abdomen
Answer:
a. Dark, red vaginal bleeding
d. Increased uterine irritability
f. A rigid abdomen
The symptoms of abruptio placentae include dark red vaginal bleeding (A), increased uterine irritability (D), and a rigid abdomen (F).
QUESTION
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
a. Insert an internal fetal monitor
b. Assess for cervical changes q1h
c. Monitor bleeding from IV sites
d. Perform Leopold's maneuvers
Answer:
c. Monitor bleeding from IV sites
Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruption, characterized by abnormal bleeding.
QUESTION
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge?
a. Supplementary iron is more efficiently utilized during pregnancy
b. It difficult to consume 18 mg of additional iron by diet alone
c. Iron absorption is decreased in the GI tract during pregnancy
d. Iron is needed to prevent megaloblastic anemia in the last trimester
Answer:
b. It difficult to consume 18 mg of additional iron by diet alone
Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult (B) so iron supplements are often recommended.
QUESTION
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?
a. Transition labor with contractions every 2 minutes, lasting 90 seconds each
a. Early labor with contractions every 5 minutes, lasting 40 seconds each
c. Active labor with contractions every 31 minutes, lasting 60 seconds each
d. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each
Answer:
a. Transition labor with contractions every 2 minutes, lasting 90 seconds each
Contractions pattern (A) describes hyperstimulation and an inadequate resting time between contractions to allow for placental perfusion. The oxytocin infusion should be discontinued.
QUESTION
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
a. She eagerly reaches for the infant, undresses the infants, and examines the infant completely
b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips
c. Her arms and hands receive the infant and she then cuddles the infant to her own body
d. She eagerly reaches for the infant and then holds the infant close to her own body
Answer:
b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips
Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in (B) during the first visit with the newborn, which may be at delivery of later.
QUESTION
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching on the gravid client?
a. The client's readiness to learn
b. The client's educational background
c. The order in which the information is presented
d. The extent to which the pregnancy was planned
Answer:
When teaching any client, readiness to learn (A) is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be "ready to learn" about ways to relieve morning sickness.
QUESTION
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order)
a. Provide oxygen via face mask
b. Reposition the client
c. Increase IV fluid
d. Call the healthcare provider
Answer:
1. Reposition the Client - b.
2. Provide oxygen via face mask - a.
3. Increase IV fluid - c.
4. Call the healthcare provider - d.
To stabilize the fetus, intrauterine resuscitation is the first priority, and to enhance the fetal blood supply, the laboring client should be repositioned (1) to displace the gravid uterus and improve fetal perfusion. Secondly, to optimize oxygenation of the circulatory blood volume, oxygen via face mask (2) should be applied to the mother. Next, the IV fluids should be increased (3) to expand the maternal circulating blood volume. Then, the primary healthcare provider should be notified (4) for additional interventions to resolve the fetal stress.
QUESTION
The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant?
a. Herpes
b. Staphylococcus
c. Gonorrhea
d. Syphilis
Answer:
c. Gonorrhea
Erythromycin ointment is instilled into the lower conjunctive of each eye within 2 hours after birth to prevent ophthalmic neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia (C). The infant may be exposed to these bacteria when passing the birth canal.
QUESTION
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
a. Elicit positive scarf sign on the affected side
b. Observe for an asymmetrical Moro (startle) reflex
c. Watch for swelling of fingers on the affected side
d. Note paralysis of affected extremity and muscles
Answer:
b. Observe for an asymmetrical Moro (startle) reflex
The most common neonatal birth trauma due to vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fracture clavicle should be suspected is an infant has limited use of the affected arm malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.
QUESTION
The nurse is calculating the estimated date of confinement (EDC) using Nagele's rule for a client whose last menstrual period started on December 1. Which date is most accurate?
a. August 1
b. August 10
c. September 3
d. September 8
Answer:
d. September 8
Calculation of a client's EDC provides baseline data to monitor fetal gestation. Nagele's rule uses the formula: subtract 3 months and add 7 days to the first day of the last normal menstrual period, so December 1 minus 3 months + 7 days is September 8 (D).
QUESTION
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important is most important for the nurse to provide this client?
a. Elevate lower legs while resting
b. Increase caloric intake by 200 to 300 calories per day
c. Increase water intake to 8 full glasses per day
d. Take prescribed multivitamin and mineral supplements
Answer:
d. Take prescribed multivitamin and mineral supplements
A client who has had a spontaneous abortion or still birth in the last 1.5 years should take multivitamin and mineral supplements (D) and maintain a balanced diet because the previous pregnancy may have left her nutritionally depleted.
QUESTION
The total bilirubin level of a 36-hour, breastfeeding newborns is 14 mg/dl. Based on this finding, which intervention should the nurse implement?
a. Feed the newborn sterile water hourly
b. Encourage the mother to breastfeed frequently
c. Assess the newborn's blood glucose level
d. Encourage the mother to breastfeed frequently
Answer:
b. Encourage the mother to breastfeed frequently
The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb, and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin (C).
QUESTION
Which assessment finding should the nursery nurse report to the pediatric healthcare provider?
a. Blood glucose level of 45 mg/dl
b. Blood pressure of 82/45 mmHg
c. Non-bulging anterior fontanel
d. Central cyanosis when crying
Answer:
d. Central cyanosis when crying
An infant who demonstrates central cyanosis when crying (D) is manifesting poor adaptation to extrauterine life which should be reported to the healthcare provider for determination of a possible underlying cardiovascular problem.
QUESTION
A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
a. Encourage the mother to provide total care for her infant
b. Provide privacy, so the mother can develop a relationship with the infant
c. Encourage the father to provide most of the infant's care during hospitalization
d. Meet the mother's physical needs and demonstrate warmth toward the infant [Show Less]
