HESI RN Maternity V3 | NCLEX Questions and Verified Answers with Rationales (2023/2024)
QUESTION
A new mother who has just had her first baby says to
... [Show More] 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 unusually shaped head, especially for a first baby."
B. "It may look odd, but newborn babies are often born with heads like that."
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 head had to adjust to the birth canal."
Answer:
C
Rationale:
Option C reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although option A is correct, it implies that the client should not worry. Any implied or spoken "don't worry" is usually the wrong answer. Option B is condescending and dismissing; the mother is seeking reassurance and information. Option D is a negative statement and implies that molding is the mother's fault.
QUESTION
Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.)
A. Increased heartburn that is not relieved with doses of antacids
B. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit
C. Shoes and rings that are too tight because of peripheral edema in extremities
D. Decrease in ability for the client to sleep for more than 2 hours at a time
E. Chronic headache that has been lingering for a week behind the client's eyes
Answer:
A, E
Rationale:
Options A and E are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs during the last trimester of pregnancy.
QUESTION
Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.)
A. Cramping with bright red spotting
B. Extreme tenderness of the breast
C. Lack of tenderness of the breast
D. Increased amounts of discharge
E. Increased right-side flank pain
Answer:
A, C, E
Rationale:
Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. Options B and D are normal signs during the first trimester of a pregnancy.
QUESTION
During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother?
A. Lower Apgar score recorded at delivery
B. Lower initial weight documented at birth
C. Higher oxygen use to stimulate breathing
D. Higher prevalence of congenital anomalies
Answer:
B
Rationale:
Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not to smoke during pregnancy. Options A, C, and D have not been clearly associated with smoking during pregnancy, but there is a strong correlation between smoking and lower birth weights.
QUESTION
When preparing a class on newborn care for expectant parents, which is correct for the nurse to 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.
Answer:
C
Rationale:
Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth through the third or fourth month and does not require surgery.
QUESTION
Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?
A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period."
B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk."
C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk."
D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings."
Answer:
A
Rationale:
Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method. Option B is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk. Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings.
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