Maternity HESI Assignment Exam - Questions, Answers and Rationales Which prescription should the nurse administer to a newborn to reduce complications
... [Show More] related to birth trauma? Vitamin K (AquaMEPHYTON). Rationale: The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels and reduce the risk of neonatal bleeding, newborns receive a single injection of vitamin K (AquaMEPHYTON). At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention? Uterine cramping. Rationale: The client should be monitored for 1 to 2 hours following the procedure for the occurrence of uterine cramping so that immediate intervention to decrease the risk of miscarriage can be initiated. This procedure (removal of a small piece of tissue from the fetal portion of the placenta) may cause initiation of labor. A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider? Respiratory rate of 11 breaths/minute. Rationale: A sign of magnesium toxicity is respiratory depression, so the client's respiration rate of 11 breaths/minute should be reported to the healthcare provider. A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding? 3.5 ounces. Rationale: A newborn requires approximately 19 to 21 ounces of formula each day (six feedings per 24-hour period x 3.5 = 21). Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day? Exhibit interest in learning more about infant care. Rationale: By the third postpartum day, the new mother should start to "take hold" of caring for her infant, by asking questions about infant care and initiating care of her infant. What information should the nurse include about perineal self-care for a client who is 24-hours post-delivery? Spray warm water from front to back using a squeeze bottle. Rationale: A postpartum client should use a squeeze bottle after each void and clean from front to back. A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time? Observe interactions of family members with the newborn and each other. Rationale: An opportunity to assess the emotional adjustment of individual family members to birth and lifestyle changes is presented, so the nurse should first observe the interaction of the family members. [Show Less]