HESI Maternal/Pediatric V2 QUESTIONS AND ANSWERS (GRADED A)
Client teaching is an important part of the maternity nurse's role. Which factor has the
... [Show More] greatest influence on successful teaching of 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 is planned Correct Answer: A
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?
a. wearing support stockings
b. reduce salt in her diet
c. move about every hour
d. avoid constrictive clothing Correct Answer: C
During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have
a. lower apgar scores
b. lower birth weights
c. respiratory distress
d. a higher rate of congenital anomalies Correct Answer: B
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate?
a. drowsiness and bradycardia
b. depressed reflexes and increased respirations
c. tachycardia and a feeling of nervousness.
d. a flushed, warm feeling and a dry mouth Correct Answer: C
A mother who is breastfeeding her baby receives instructions from the nurse. Which instructions is most effective to prevent nipple soreness?
a. wear a cotton bra
b. increase nursing time gradually
c. correctly place the infant on the breast
d. manually express a small amount of milk before nursing Correct Answer: C
A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?
a. length of labor and method of delivery
b. infant's condition at birth and treatment received
c. feeding methods chosen by the parents
d. history of drugs given to the mother during labor Correct Answer: B
In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal new born, the
a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week
b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week
c. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month
d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. Correct Answer: D
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
a. at 16-week gestation
b. at 20-weeks gestation
c. at 24-weeks gestation
d. at 30-weeks gestation Correct Answer: D
The nurse should encourage the laboring client to begin pushing when
a. there is only an anterior or posterior lip of cervix left.
b. the client describes the need to have a bowel movement
c. the cervix is completely dilated
d. the cervix is completely effaced Correct Answer: C
The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs
a. two weeks before menstruation
b. immediately after menstruation
c. immediately before mensturation
d. three weeks before menstruation Correct Answer: A
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?
a. administer oxygen by face mask.
b. notify the healthcare provider of the client's symptoms.
c. have the client breathe into her cupped hands
d. check the client's blood pressure and fetal heart rate Correct Answer: C
When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation?
a. milia are red marks made by forceps and will disappear within 7 to 10 days
b. meconium is the first stool and is usually yellow gold in color
c. vernix is a white, cheesy substance, predominantly located in the skin folds.
d. pseudostrabismus found in newborns is treated by minor surgery Correct Answer: C
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as
a. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks.
b. a subarachnoid hematoma, which requires immediate drainage to prevent further complications
c. modeling, caused by pressure during labor and will disappear within 2 to 3 days
d. a subdural hematoma which can result in lifelong damage Correct Answer: A
An expectant father tells the nurse he fears that his wife "is losing her mind". He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?
a. reassure him that these are normal reactions to pregnancy and suggest that she discuss his concerns with the childbirth education nurse
b. help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed.
c. ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit.
d. let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement. Correct Answer: D
A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best?
a. "this is not an unusual shaped head, especially for a first baby."
b. "it may look funny to you, but newborn babies are often born with heads like your baby's"
c. "that is normal; the head will return to a round shape within 7 to 10 days."
d. "your pelvis was too small, so the baby's head had to adjust to the birth canal." Correct Answer: C
A new mother asks the nurse, "how do I know that my daughter is getting enough breast milk?" Which explanation will the nurse provide?
a. "weight the baby daily, and if she is gaining weight, she is eating enough."
b. "your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day."
c. "Offer the baby extra bottle milk after her feeding, and see if she is still hungry."
d. "If you're concerned, you might consider bottle feeding so that you can monitor her intake." Correct Answer: B
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. Correct Answer: D
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingogrphy is scheduled. Which complaint would indicate to the nurse that the woman's fallopian tubes are patent?
a. back pain
b. abdominal pain
c. shoulder pain
d. leg cramps Correct Answer: C
Which nursing intervention would be most helpful in relieving postpartum uterine contractions or "afterpains"?
a. lying prone with a pillow on the abdomen
b. using a breast pump
c. massaging the abdomen
d. giving oxytocic medications Correct Answer: A
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 infant, 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 hold the infant close to her own body Correct Answer: B
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery would be
a. November 22
b. November 8
c. December 22
d. October 22 Correct Answer: A
The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period will be
a. January 14-15
b. January 22-23
c. January 30-31
d. February 6-7 Correct Answer: C
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment findings would indicate that therapeutic drug level has been achieved?
a. 4+ reflexes
b. urinary output of 50 mL per hour
c. a decrease in respiratory rate from 24 to 16
d. a decreased body temperature Correct Answer: C
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take?
a. notify the healthcare provider or anesthesiologist immediately
b. continue to assess the blood pressure q 5 minutes
c. place the woman in a lateral position
d. turn off the continuous epidural Correct Answer: C
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
a. come to the clinic today for an ultrasound
b. go immediately to the emergency room
c. lie on your left side for about one hour and see if the bleeding stops.
d. bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection Correct Answer: A
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help her wife. Which intervention has the highest priority?
a. use a thread to tie off the umbilical cord
b. provide as much privacy as possible for the woman.
c. reassure the husband and try to keep him calm
d. put the newborn to breast Correct Answer: D
A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "why must I stay in bed all the time?" Which response is best for the nurse to provide this client?
a. "complete bedrest decreases oxygen needs and demands on the heart muscle tissue."
b. "we want your body to be healthy, and this is the only way we can make sure that will happen."
c. "I know you're upset. Would you like to talk about some things you could do while in bed?"
d. "labor is difficult and you need to use this time to rest before you have to assume all child-caring duties." Correct Answer: A
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 Correct Answer: C
A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first?
a. notify the pediatrician immediately
b. suction the infant's nares, then the oral cavity
c. check the infant's oxygen saturation rate
d. position the infant on the right side Correct Answer: C
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first?
a. assess the husband's feelings about his wife's decision to breastfeed their baby
b. ask the client to describe why she was unsuccessful with breastfeeding her last child
c. encourage the clients to develop a positive attitude about breastfeeding to help ensure success
d. provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Correct Answer: D
The nurse is teaching a woman how to use her basal body temperature pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
a. between the time the temperature falls and rises
b. between 36 and 48 hours after the temperature rises
c. when the temperature fails and remains low for 36 hours.
d. within 72 hours before the temperature falls Correct Answer: A
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction 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 Correct Answer: D
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptoms for a pediatric client with AIDS is
a. shortness of breath
b. joint pain
c. a persistent cold
d. organomegaly Correct Answer: C
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment finding are of greatest concern?
a. edema, basilar rales, and an irregular pulse
b. increased urinary output and tachycardia
c. shortness of breath, bradycardia, and hypertension
d. regular heart rate and hypertension Correct Answer: A
A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?
a. describe diet changes that can improve the management of her diabetes.
b. inform the client that oral hypoglycemic agents are teratogenic during pregnancy
c. demonstrate self-administration of insulin
d. evaluate the client's ability to do glucose monitoring Correct Answer: A
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
a. raise the foot of the bed
b. assess for vaginal bleeding
c. evaluate the fetal heart rate
d. take the client's blood pressure Correct Answer: A
The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dL. Based on this finding, which intervention should the nurse implement?
a. provide phototherapy for 30 minutes q8hour
b. feed the newborn sterile water hourly
c. encourage the mother to breastfeed frequently
d. assess the newborn's blood glucose level Correct Answer: C
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity?
a. deep tendon reflexes 2+
b. blood pressure 140/90
c. respiratory rate 18/minute
d. urine output 90 mL/4 hours Correct Answer: D
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug?
a. maternal blood pressure and respirations
b. maternal and fetal heart rates
c. hourly urinary output
d. deep tendon reflexes Correct Answer: B
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit?
a. choking, coughing, and cyanosis
b. projectile vomiting and cyanosis
c. apneic spells and grunting
d. scaphoid abdomen and anorexia Correct Answer: A
The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate?
a. grief related to her perceptions about the loss of this child.
b. relief of ambivalent feelings experienced with this pregnancy.
c. shock because she may not have realized that she was pregnant.
d. guilt because she had not followed her healt [Show Less]