A home care nurse is instructing a client with hyperemesis
gravidarum about measures to ease the nausea and vomiting.
The nurse tells the client to:
A
... [Show More] Eat foods high in calories and fat
B Lie down for at least 20 minutes after meals
C Eat carbohydrates such as cereals, rice, and pasta Correct
D Consume primarily soups and liquids at mealtimes Incorrect
Rationale: Low-fat foods and easily digested carbohydrates
such as fruit, breads, cereals, rice, and pasta provide important
nutrients and help prevent a low blood glucose level, which can
cause nausea. Soups and other liquids should be taken between
meals to avoid distending the stomach and triggering nausea.
Sitting upright after meals reduces gastric reflux. Additionally,
food portions should be small and foods with strong odors should
be eliminated from the diet, because food smells often incite
nausea.
Test-Taking Strategy: Use the process of elimination and
focus on the client’s diagnosis and the subject, ways to ease and
prevent nausea and vomiting. Knowing that foods high in fat may
be difficult to digest will assist you in eliminating this option. Next
eliminate the option that involves consuming primarily soups and
fluids at meals, recalling that liquids will cause distention of the
stomach. To select from the remaining options, recall that lying
down after meals can cause gastric reflux; this will direct you to
the correct option. Review measures to ease and prevent nausea
and vomiting if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Antepartum
Giddens Concepts: Fluid and Electrolytes, Nutrition
HESI Concepts: Fluids and Electrolytes, Nutrition
Reference: McKinney, E., James, S., Murray, S., Nelson, K. &
Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 589-590). St.
Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points.
2.ID: 9476908110A nurse is caring for a client with
preeclampsia who is receiving a magnesium sulfate infusion to
prevent eclampsia. Which finding indicates to the nurse that the
medication is effective?
A Clonus is present.
B Magnesium level is 10 mg/dL (4.11 mmol/L)
C Deep tendon reflexes are absent.
D The client experiences diuresis within 24 to 48 hours. Correct
Rationale: Magnesium sulfate is effective in preventing
seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the
start of the infusion. As part of the therapeutic response, renal
perfusion is increased and the client is free of visual disturbances,
headache, epigastric pain, clonus (the rapid rhythmic jerking
motion of the foot that occurs when the client’s lower leg is
supported and the foot is sharply dorsiflexed), and seizure
activity. Hyperreflexia indicates cerebral irritability. Clonus is
normally not present. The therapeutic magnesium level is 4 to 8
mg/dL (1.64 to 3.29 mmol/L). Reflexes range from 1+ to 2+ but
should not be absent.
Test-Taking Strategy: Use the process of elimination and
focus on the strategic words “medication is effective.” Recalling
the actions of this medication and expected assessment findings
after a client receives magnesium sulfate will direct you to this
option. Review the expected assessment findings for a client
receiving magnesium sulfate if you had difficulty with this
question.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Evidence, Perfusion
HESI Concepts: Evidence-Based Practice/Evidence,
Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. &
Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 594-595). St.
Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
3.ID: 9476908130A client with preeclampsia who is receiving
magnesium sulfate in an intravenous infusion exhibits signs of
magnesium toxicity. The nurse immediately prepares for the
administration of:
A Vitamin K
B Protamine sulfate
C Calcium gluconate Correct
D Naloxone hydrochloride
Rationale: Calcium gluconate is the antidote to magnesium
sulfate because it antagonizes the effects of magnesium at the
neuromuscular junction. It should be readily available whenever
magnesium is administered. Vitamin K is the antidote in cases of
hemorrhage induced by the administration of oral anticoagulants
such as warfarin sodium (Coumadin). Protamine sulfate is the
antidote in cases of hemorrhage induced by the administration of
heparin. Naloxone hydrochloride is administered to treat opioidinduced respiratory depression.
Test-Taking Strategy: Focus on the subject of the question,
the treatment for magnesium toxicity. Specific knowledge
regarding antidotes and the process of elimination will assist in
directing you to the correct option. Review common antidotes if
you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment,
Safety
Reference: Gahart, B., & Nazareno, A. (2015). 2015
Intravenous medications (31st ed., p. 773). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4.ID: 9476908194A nurse instructs a pregnant client about
foods that are high in folic acid. Which item does the nurse tell
the client is the best source of folic acid?
A Milk
B Steak
C Chicken
D Lima beans Correct
Rationale: The best sources of folic acid are liver; kidney,
pinto, lima, and black beans; and fresh dark-green leafy
vegetables. Other good sources of folic acid are orange juice,
peanuts, refried beans, and peas. Milk is high in calcium. Chicken
and steak are high in protein.
Test-Taking Strategy: Use the process of elimination and
focus on the subject, the best source of folic acid. Eliminate the
options that are comparable or alike in that they are high in
protein. Next eliminate milk, recalling that milk is high in calcium.
Review the foods high in folic acid if you had difficulty with this
question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Nutrition
Giddens Concepts: Nutrition, Reproduction
HESI Concepts: Metabolism – Nutrition, Sexuality,
Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. &
Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 282-283). St.
Louis: Elsevier.
Nix, S. (2013). Williams’ basic nutrition and diet therapy
(14th ed., pp. 114, 119). St. Louis: Mosby. Awarded 1.0 points out
of 1.0 possible points.
5.ID: 9476904403A nurse is providing instructions to a mother
of an infant with seborrheic dermatitis (cradle cap) about
treatment of the condition. The nurse tells the mother to:
A Avoid the use of shampoo on the infant’s scalp
B Apply oil to the affected area on the infant’s scalp Correct
C Wash the infant’s scalp daily, using only tepid water
D Shampoo the infant’s scalp, avoiding the anterior fontanel area
Rationale: Seborrheic dermatitis, a chronic inflammation of
the scalp or other areas of the skin, is characterized by yellow,
scaly, oily lesions. It sometimes results when parents do not wash
over the anterior fontanel carefully for fear that they will hurt the
infant. Treatment includes the application of oil (e.g., mineral oil)
to the area to help soften the lesions followed by gentle removal
of the scaly lesions with a comb before the head is shampooed.
The nurse should teach the mother how to shampoo the scalp and
explain that she will not damage the fontanel with normal gentle
shampooing. The scalp should be rinsed well to remove all soap,
which could cause irritation.
Test-Taking Strategy: Use the process of elimination.
Eliminate the option containing the closed-ended word “only.” To
select from the remaining options, recall that this condition is
characterized by the presence of scaly lesions; this will direct you
to the correct option. Review the treatment for seborrheic
dermatitis (cradle cap) if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Newborn
Giddens Concepts: Client Education, Tissue Integrity
HESI Concepts: Teaching and Learning/Patient Education,
Tissue Integrity
Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s
nursing care of infants and children (10th ed. pp. 467-468). St
Louis: Mosby. Awarded 1.0 points out of 1.0 possible points.
6.ID: 9476901633A nurse is monitoring a client who was given
an epidural opioid for a cesarean birth. The nurse notes that the
client’s oxygen saturation on pulse oximetry is 92%. The nurse
first:
A Documents the findings
B Contacts the health care provider
C Administers 100% oxygen by way of face mask
D Instructs the client to take several deep breaths Correct
Rationale: If the client has been given an epidural opioid, the
nurse should monitor the client’s respiratory status closely. If the
oxygen saturation falls below 95%, the nurse instructs the client
to take several deep breaths to increase the level. Although the
finding would be documented, action is required to increase the
oxygen saturation level. It is not necessary to contact the health
care provider. If the deep breaths fail to increase the oxygen
saturation level, the health care provider is notified and may
prescribe oxygen.
Test-Taking Strategy: Use the process of elimination and
focus on the data in the question. Noting the oxygen saturation
level will assist you in eliminating this option. Noting the strategic
word “first” will direct you to the correct option. Review care of
the client after a cesarean birth if you had difficulty with this
question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Clinical Judgment, Gas Exchange
HESI Concepts: Clinical Decision-Making/Clinical Judgment,
Oxygenation/Gas Exchange
Reference: McKinney, E., James, S., Murray, S., Nelson, K. &
Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 430-431). St.
Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
7.ID: 9476904487A client who delivered a healthy newborn 11
days ago calls the clinic and tells the nurse that she is
experiencing a white vaginal discharge. The nurse tells the client:
A To perform a vaginal douche
B To come to the clinic for a checkup
C That this is an indication of an infection
D That this is a normal postpartum occurrence Correct
Rationale: For the first 3 days following childbirth, lochia
consists almost entirely of blood, with small particles of decidua
and mucus, and is called lochia rubra because of its red color. The
amount of blood decreases by about the fourth day, and which
time the lochia changes from red to pink or brown-tinged; this
stage is called lochia serosa. By about the 11th day, the
erythrocyte component of lochia has decreased and the discharge
becomes white or cream-colored. This final stage is known as
lochia alba. Lochia alba contains leukocytes, decidual cells,
epithelial cells, fat, cervical mucus, and bacteria. It is present in
most women until the third week after childbirth but may persist
for as long as 6 weeks. Lochia alba is a normal finding during the
postpartum course, and no intervention is required, so the other
options are incorrect.
Test-Taking Strategy: Use your knowledge of expected
postpartum findings to answer the question. Recalling the normal
expected occurrences in regard to vaginal discharge will direct
you to the correct option. Also, noting that the incorrect options
are comparable or alike will direct you to the correct option.
Review normal postpartum findings in regard to lochia if you had
difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Clinical Decision-Making/Clinical Judgment,
Sexuality/Reproduction Reference: McKinney, E., James, S.,
Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing
(4th ed., p. 435). St. Louis: Elsevier. Awarded 1.0 points out of 1.0
possible points.
8.ID: 9476908170A rubella antibody screen is performed in a
pregnant client, and the results indicate that the client is not
immune to rubella. The nurse tells the client that:
A A rubella vaccine must be administered immediately
B A rubella vaccine must be administered after childbirth Correct
C She will not contract rubella if she is exposed to the disease
D She does not need to be concerned about being exposed to
rubella
Rationale: A prenatal rubella antibody screen is performed in
every pregnant woman to determine whether she is immune to
rubella, which can cause serious fetal anomalies. If she is not
immune, rubella vaccine is offered after childbirth to keep her
from contracting rubella during subsequent pregnancies. The
vaccine is a live virus, and defects might occur in the fetus if the
vaccine were administered during pregnancy or if the mother
were to become pregnant soon after it was administered.
Administering a rubella vaccine immediately places the fetus at
risk. Telling the client that she does not need to be concerned
about being exposed to rubella is incorrect, because the
possibility of exposure, which could be harmful to the fetus, does
exist.
Test-Taking Strategy: Use the process of elimination.
Eliminate first the options that are comparable or alike (i.e., the
client will not acquire rubella and does not need to be concerned
about exposure). To select from the remaining options, recall that
rubella vaccine is a live virus; this will direct you to the correct
option. Review rubella vaccine and its implications during
pregnancy if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Giddens Concepts: Immunity, Safety
HESI Concepts: Immunity, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. &
Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 439-440). St.
Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
9.ID: 9476908162A nurse is monitoring a client who delivered
a healthy newborn 12 hours ago. The nurse takes the client’s
temperature and notes that it is 38° C (100.4° F). The most
appropriate nursing action would be to:
A Contact the health care provider
B Recheck the temperature in 1 hour
C Encourage the intake of oral fluids Correct
D Tell the client that antibiotics will be prescribed
Rationale: A temperature of 38° C (100.4° F) is common
during the 24 hours after childbirth. It may be the result of
dehydration or normal postpartum leukocytosis. If the increased
temperature persists for longer than 24 hours or exceeds 38° C,
infection is a possibility, and the fever is reported to the health
care provider or nurse midwife. Because the client delivered her
baby just 12 hours ago, the most appropriate nursing action is to
encourage the intake of oral fluids.
Test-Taking Strategy: Use the process of elimination. Note
the strategic words “12 hours ago.” Recalling that a low-grade
temperature is a common postpartum assessment finding will
direct you to the correct option. Review normal vital sign findings
during a postpartum assessment if you had difficulty with this
question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Giddens Concepts: Reproduction, Thermoregulation
HESI Concepts: Sexuality/Reproduction, Thermoregulation
Reference: McKinney, E., James, S., Murray, S., Nelson, K. &
Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 441). St.
Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
10.ID: 9476910071A nurse is assessing the uterine fundus of a
client who has just delivered a baby and notes that the fundus is
boggy. The nurse massages the fundus, and then presses to expel
clots from the uterus. To prevent uterine inversion during this
procedure, the nurse:
A Has the client void before the uterine assessment
B Tells the woman to bear down during fundal message
C Simultaneously provides pressure over the lower uterine segment
Correct
D Asks the client to take slow, deep breaths during fundal
assessment
Rationale: After massaging a boggy fundus until it is firm, the
nurse presses the fundus to expel clots from the uterus. The nurse
must also keep one hand pressed firmly just above the symphysis
(over the lower uterine segment) the entire time. Removing the
clots allows the uterus to contract properly. Providing pressure
over the lower uterine segment prevents uterine inversion.
Having the client void before uterine assessment will not prevent
uterine inversion. Telling the woman to bear down while the nurse
performs fundal message and asking the client to take slow, deep
breaths during fundal assessment also will not prevent uterine
inversion.
Test-Taking Strategy: Use the process of elimination, focusing
on the subject, prevention of uterine inversion. Visualizing each of
the actions in the options and relating the action to the subject of
the question will direct you to the correct option. Review fundal
assessment and massage if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Giddens Concepts: Reproduction, Safety
HESI Concepts: Sexuality/Reproduction, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. &
Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 442, 668). [Show Less]