HESI RN Maternity V2| Questions and Verified Answers (2023/2024 Update)
QUESTION
A primigravida at 37 weeks gestation tells the nurse that her "bag of
... [Show More] water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement?
-administer 10 L of oxytocin via face mask
-give the HCP a status report
-place client in knee-chest position
-wrap the cord with glaze soaked in saline
Answer:
C. Place the client in the knee-chest position
QUESTION
The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion?
-client needs to void
-amniotic membranes rupture
-uterine contractions occur every 8-10 min
-FHR is 180 bpm w/o variability
Answer:
D. The fetal heart rate is 180 bpm without variability
QUESTION
The nurse on the postpartum unit receives report for 4 clients during change of shift. Which client should the nurse assess for risk of postpartum hemorrhage?
-primigravida who had spontaneous birth of preterm twins
-multigravida who delivered an 8 lb 2 oz infant after 8 hour labor
-multiparous client receiving magnesium sulfate during induction for severe preeclampsia
-primiparous client who had an emergency cesarean birth due to fetal distress
Answer:
C. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia
QUESTION
What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal?
-play soft music and talk to soothe the infant
-administer chloral hydrate for sedation
-feed every 4-6 hours to allow extra rest
-swaddle the infant snugly and hold tight
Answer:
D. Swaddle the infant snugly and hold tightly
QUESTION
The father of a newborn tells the nurse, "My son just died." how should the nurse respond?
-I am sorry for your loss
-there is an angel in heaven
-I understand how you feel
-you can have other children
Answer:
A. "I am sorry for your loss."
QUESTION
A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action?
-assess newborn reflexes for signs of neuro impairment
-leave infant in the room with the mother to foster attachment
-obtain serum glucose levels frequently while observing closely for signs of hypoglycemia
-perform a gestational age assessment to determine if the infant is large for gestational age
Answer:
C. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia
QUESTION
An infant who weighs 3.8 kg is delivered vaginally at 39 weeks gestation with a nuchal cord after a 30 minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide?
-further assessment is indicated
-petechiae occurs with forceps delivery
-an increased blood volume causes broken blood vessels
-pinpoint spots are benign and disappear within 48 hours
Answer:
D. The pinpoint spots are benign and disappear within 48 hours
QUESTION
Which finding for a client in labor at 41 weeks gestation requires additional assessment by the nurse?
-cervix dilated 2 cm and 50% effaced
-score of 8 on the biophysical profile
-fetal heart rate of 116 bpm
-one fetal movement noted in an hour
Answer:
D. One fetal movement noted in an hour
QUESTION
A primigravida at 12 weeks gestation who just moved to the United States indicates she has not received any immunizations. Which Immunizations should the nurse administer at this time? (Select all that apply)
Answer:
A. Tetanus
C. Diphtheria
E. Hepatitis B
QUESTION
A gravid client develops maternal hypotension following regional anesthesia. What interventions should the nurse implement? (Select all that apply)
Answer:
A. Administer oxygen
B. Increase IV fluids
E. Place the client in a lateral position
F. Monitor fetal status
QUESTION
A client at 29 weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client?
-amniocentesis
-ultrasonography
-chorionic villus sampling
-maternal serum alpha-fetoprotein
Answer:
B. Ultrasonography
QUESTION
The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide?
-kidneys and renal function are not fully developed
-warmth promotes sleep so the infant will grow quickly
-a large body surface area favors heat loss to the environment
-thick layer of subcut fat is inadequate for insulation
Answer:
C. A large body surface area favors heat loss to the environment
QUESTION
The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?
-ask mother why she won't look at infant [Show Less]