,BSN366 Exam 4 Actual Exam Style V3 | BSN 366
HESI RN Exit | Nightingale
Complete Questions 1-150
SECTION 1: MATERNITY & NEWBORN NURSING
(Questions 1-30)
QUESTION 1
A client in active labor experiences prolonged second stage. After the fetal
head delivers, it retracts tightly against the perineum and does not recede.
Which action should the nurse take immediately?
A. Apply gentle suprapubic pressure
B. Position the client in a hands-and-knees position
C. Call for assistance and prepare for shoulder dystocia maneuvers
D. Apply fundal pressure
Correct Answer: C. Call for assistance and prepare for shoulder dystocia
maneuvers
*Rationale: * The turtle sign (retraction of the fetal head against the
perineum) indicates shoulder dystocia. The nurse should call for assistance
,and prepare for maneuvers such as McRoberts' position and suprapubic
pressure. Fundal pressure should be avoided as it can worsen the
impaction.
QUESTION 2
The nurse is assessing a client at 36 weeks gestation who reports a sudden
gush of fluid from the vagina. Which action should the nurse take first?
A. Check the fetal heart rate
B. Assess the fluid for color and odor
C. Perform a nitrazine test
D. Notify the provider
Correct Answer: A. Check the fetal heart rate
*Rationale: * After ruptured membranes, the priority is to assess fetal heart
rate to identify any signs of cord compression or fetal distress. The nurse
should then assess the fluid for color, odor, and amount.
QUESTION 3
A newborn is 5 minutes old and has Apgar scores of 7 at 1 minute and 9 at
5 minutes. Which finding contributes to the 1-minute score?
A. The newborn is pink with acrocyanosis
B. The newborn has weak cry
C. The newborn has a heart rate of 140
D. The newborn has flexed extremities
, Correct Answer: B. The newborn has weak cry
*Rationale: * An Apgar score of 7 indicates some compromise. Weak cry
would decrease the score. A heart rate of 140 (2 points), pink with
acrocyanosis (1 point for color), and flexed extremities (2 points) are all
normal.
QUESTION 4
A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A. Respiratory rate of 16 breaths/min
B. Urine output of 40 mL/hr
C. Absent deep tendon reflexes
D. Serum magnesium level of 5 mEq/L
*Correct Answer: C. Absent deep tendon reflexes
*Rationale: * Absent deep tendon reflexes (DTRs) is a sign of magnesium
toxicity. Respiratory rate below 12, urine output below 30 mL/hr, and serum
magnesium levels above 7-8 mEq/L are also signs of toxicity. The antidote
is calcium gluconate.
QUESTION 5
HESI RN Exit | Nightingale
Complete Questions 1-150
SECTION 1: MATERNITY & NEWBORN NURSING
(Questions 1-30)
QUESTION 1
A client in active labor experiences prolonged second stage. After the fetal
head delivers, it retracts tightly against the perineum and does not recede.
Which action should the nurse take immediately?
A. Apply gentle suprapubic pressure
B. Position the client in a hands-and-knees position
C. Call for assistance and prepare for shoulder dystocia maneuvers
D. Apply fundal pressure
Correct Answer: C. Call for assistance and prepare for shoulder dystocia
maneuvers
*Rationale: * The turtle sign (retraction of the fetal head against the
perineum) indicates shoulder dystocia. The nurse should call for assistance
,and prepare for maneuvers such as McRoberts' position and suprapubic
pressure. Fundal pressure should be avoided as it can worsen the
impaction.
QUESTION 2
The nurse is assessing a client at 36 weeks gestation who reports a sudden
gush of fluid from the vagina. Which action should the nurse take first?
A. Check the fetal heart rate
B. Assess the fluid for color and odor
C. Perform a nitrazine test
D. Notify the provider
Correct Answer: A. Check the fetal heart rate
*Rationale: * After ruptured membranes, the priority is to assess fetal heart
rate to identify any signs of cord compression or fetal distress. The nurse
should then assess the fluid for color, odor, and amount.
QUESTION 3
A newborn is 5 minutes old and has Apgar scores of 7 at 1 minute and 9 at
5 minutes. Which finding contributes to the 1-minute score?
A. The newborn is pink with acrocyanosis
B. The newborn has weak cry
C. The newborn has a heart rate of 140
D. The newborn has flexed extremities
, Correct Answer: B. The newborn has weak cry
*Rationale: * An Apgar score of 7 indicates some compromise. Weak cry
would decrease the score. A heart rate of 140 (2 points), pink with
acrocyanosis (1 point for color), and flexed extremities (2 points) are all
normal.
QUESTION 4
A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A. Respiratory rate of 16 breaths/min
B. Urine output of 40 mL/hr
C. Absent deep tendon reflexes
D. Serum magnesium level of 5 mEq/L
*Correct Answer: C. Absent deep tendon reflexes
*Rationale: * Absent deep tendon reflexes (DTRs) is a sign of magnesium
toxicity. Respiratory rate below 12, urine output below 30 mL/hr, and serum
magnesium levels above 7-8 mEq/L are also signs of toxicity. The antidote
is calcium gluconate.
QUESTION 5
