Hesi Med - Surg Maternity Nclex Predictor
Final Exam 2 Real Exam Complete Verified
Questions And Correct Detailed Answers
(Verified Rationales) |Already Graded A+
1. A pregnant woman's mother is worried that her daughter is not "big enough" at
20 weeks. The
nurse palpates and measures the fundal height at 20 cm, which is even with the
woman's
umbilicus. What should the nurse report to the woman and her mother?
a. "The body of the uterus is at the belly button level, just where it should be at
this
time."
b. "You're right. We'll inform the practitioner immediately."
c. "When you come for next month's appointment, we'll check you again to make
sure that the baby is growing."
d. "Lightening has occurred, so the fundal height is lower than expected." -
Correct AnswerA
At 20 weeks, the fundus is usually located at the umbilical level. Because the
uterus grows in
a predictable pattern, obstetric nurses should know that the uterus of 20 weeks of
gestation is
Page 1 of 267
,located at the level of the umbilicus. There is no need to inform the practitioner.
The nurse
should reassure both mother and patient that the findings are normal. The
descent of the fetal
head (lightening) occurs in late pregnancy. PTS: 1 DIF: Cognitive Level:
Application/Applying
REF: p. 214 | p. 229 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
2. While the nurse assesses the vital signs of a pregnant woman in her third
trimester, the patient
complains of feeling faint, dizzy, and agitated. Which nursing intervention is
appropriate?
a. Have the patient stand up and retake her blood pressure.
b. Have the patient sit down and hold her arm in a dependent position.
c. Have the patient lie supine for 5 minutes and recheck her blood pressure on
both
arms.
d. Have the patient turn to her left side and recheck her blood pressure in 5
minutes. - Correct AnswerD
Blood pressure is affected by positions during pregnancy. The supine position may
cause
occlusion of the vena cava and descending aorta. Turning the pregnant woman to
a lateral
recumbent position alleviates pressure on the blood vessels and quickly corrects
supine
hypotension. Pressures are significantly higher when the patient is standing. This
option
Page 2 of 267
,causes an increase in systolic and diastolic pressures. The arm should be
supported at the
same level of the heart. The supine position may cause occlusion of the vena cava
and
descending aorta, creating hypotension. PTS: 1 DIF: Cognitive Level:
Application/Applying
REF: p. 216 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
3. A pregnant woman has come to the emergency department with complaints of
nasal
congestion and epistaxis. What action by the nurse is best?
a. Refer the patient to an ear, nose, and throat specialist.
b. Explain that nasal stuffiness and nosebleeds are caused by a decrease in
progesterone.
c. Attach the woman to a cardiac monitor, and draw blood for hemoglobin and
hematocrit.
d. Teach that the increased blood supply to the mucous membranes and can
result in
congestion and nosebleeds. - Correct AnswerD
As capillaries become engorged, the upper respiratory tract is affected by the
subsequent
edema and hyperemia, which causes these conditions, seen commonly during
pregnancy. No
referral is needed. The patient does not need to be attached to a cardiac monitor
or have lab
Page 3 of 267
, drawn. The patient should be taught that estrogen causes these changes, not
progesterone. PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 218 OBJ: Integrated Process: Teaching-Learning
MSC: Client Needs: Physiologic Integrity
4. Which finding in the urine analysis of a pregnant woman is considered a
variation of normal?
a. Proteinuria
b. Glycosuria
c. Bacteria
d. Ketonuria - Correct AnswerB
Small amounts of glucose may indicate "physiologic spilling," which occurs
because the
filtered load exceeds the renal tubules' ability to absorb them. The presence of
protein could
indicate kidney disease or preeclampsia. Urinary tract infections are associated
with bacteria
in the urine. An increase in ketones indicates that the patient is exercising too
strenuously or
has an inadequate fluid and food intake. PTS: 1 DIF: Cognitive Level:
Knowledge/Remembering
REF: p. 219 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
5. Which suggestion is appropriate for the pregnant woman who is experiencing
nausea and
vomiting?
Page 4 of 267
Final Exam 2 Real Exam Complete Verified
Questions And Correct Detailed Answers
(Verified Rationales) |Already Graded A+
1. A pregnant woman's mother is worried that her daughter is not "big enough" at
20 weeks. The
nurse palpates and measures the fundal height at 20 cm, which is even with the
woman's
umbilicus. What should the nurse report to the woman and her mother?
a. "The body of the uterus is at the belly button level, just where it should be at
this
time."
b. "You're right. We'll inform the practitioner immediately."
c. "When you come for next month's appointment, we'll check you again to make
sure that the baby is growing."
d. "Lightening has occurred, so the fundal height is lower than expected." -
Correct AnswerA
At 20 weeks, the fundus is usually located at the umbilical level. Because the
uterus grows in
a predictable pattern, obstetric nurses should know that the uterus of 20 weeks of
gestation is
Page 1 of 267
,located at the level of the umbilicus. There is no need to inform the practitioner.
The nurse
should reassure both mother and patient that the findings are normal. The
descent of the fetal
head (lightening) occurs in late pregnancy. PTS: 1 DIF: Cognitive Level:
Application/Applying
REF: p. 214 | p. 229 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
2. While the nurse assesses the vital signs of a pregnant woman in her third
trimester, the patient
complains of feeling faint, dizzy, and agitated. Which nursing intervention is
appropriate?
a. Have the patient stand up and retake her blood pressure.
b. Have the patient sit down and hold her arm in a dependent position.
c. Have the patient lie supine for 5 minutes and recheck her blood pressure on
both
arms.
d. Have the patient turn to her left side and recheck her blood pressure in 5
minutes. - Correct AnswerD
Blood pressure is affected by positions during pregnancy. The supine position may
cause
occlusion of the vena cava and descending aorta. Turning the pregnant woman to
a lateral
recumbent position alleviates pressure on the blood vessels and quickly corrects
supine
hypotension. Pressures are significantly higher when the patient is standing. This
option
Page 2 of 267
,causes an increase in systolic and diastolic pressures. The arm should be
supported at the
same level of the heart. The supine position may cause occlusion of the vena cava
and
descending aorta, creating hypotension. PTS: 1 DIF: Cognitive Level:
Application/Applying
REF: p. 216 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
3. A pregnant woman has come to the emergency department with complaints of
nasal
congestion and epistaxis. What action by the nurse is best?
a. Refer the patient to an ear, nose, and throat specialist.
b. Explain that nasal stuffiness and nosebleeds are caused by a decrease in
progesterone.
c. Attach the woman to a cardiac monitor, and draw blood for hemoglobin and
hematocrit.
d. Teach that the increased blood supply to the mucous membranes and can
result in
congestion and nosebleeds. - Correct AnswerD
As capillaries become engorged, the upper respiratory tract is affected by the
subsequent
edema and hyperemia, which causes these conditions, seen commonly during
pregnancy. No
referral is needed. The patient does not need to be attached to a cardiac monitor
or have lab
Page 3 of 267
, drawn. The patient should be taught that estrogen causes these changes, not
progesterone. PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 218 OBJ: Integrated Process: Teaching-Learning
MSC: Client Needs: Physiologic Integrity
4. Which finding in the urine analysis of a pregnant woman is considered a
variation of normal?
a. Proteinuria
b. Glycosuria
c. Bacteria
d. Ketonuria - Correct AnswerB
Small amounts of glucose may indicate "physiologic spilling," which occurs
because the
filtered load exceeds the renal tubules' ability to absorb them. The presence of
protein could
indicate kidney disease or preeclampsia. Urinary tract infections are associated
with bacteria
in the urine. An increase in ketones indicates that the patient is exercising too
strenuously or
has an inadequate fluid and food intake. PTS: 1 DIF: Cognitive Level:
Knowledge/Remembering
REF: p. 219 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
5. Which suggestion is appropriate for the pregnant woman who is experiencing
nausea and
vomiting?
Page 4 of 267
