HESI RN New Maternal

HESI RN MATERNAL NEW FILE TESTED 2022 55 Questions & Answers 1.The nurse is planning a class for pregnant women in the first trimester of pregnancy.Which information is most imported for the nurse to include in the class? B) If any vaginal bleeding occurs, notify the healthcare provider immediately 2. When assessing a pregnant woman AT 39-weeks gestation who is admitted to labor anddelivery which finding is most important to report to the health care provider? D) 101.2 oral temperature 3. A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is beingtreated with misoprostol (Cytotec), a synthetic prostaglandin C drug, how should the nurse respond? A) “You may be at risk for having a spontaneous miscarriage” 4. Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client’s medical record lists the client’s religion as Jehovah’s Witness. What action should the nurse take? C) Clarify the clients wishes about receiving blood products 5. After delivery of a normal infant, the mother tells the nurses that she would like to useoral contraceptive. Which finding in the client’s health history is a contraindication of the use of contraceptives? D) Smoked cigarettes prior to becoming pregnant 6. When planning care for a laboring client, the nurse identifies the need to withhold solidsfood while the client is in labored. What is the most important reasons for this nursing intervention? C) An increased risk of aspiration can occur if general anesthesia is needed 7. The parents of a male newborns have signed an informed consent for intervention should the nurse implement upon completion of the circumcision? A) Place petroleum gauze dressings on the site 8. The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochia flow.On inspection the nurse finds that a perineal hematoma is beginning to form. Which assessment findings show the nurse obtain first? C) Heart rate and blood pressure 9. At 6 weeks gestation the rubella titer of a client medication indicates she is nonimmune. When is the best time to administer a rubella vaccine to this client? D) Early postpartum within 72 hours of delivery 10. The nurses assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indication that the infant is transitioning well toextrauterine life? B) Cries vigorously when stimulated 11. A woman in her third trimester of pregnancy has been in active labor for the past 8hours and cervix dialed 3cm. The nurse’s assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare providerprescribes an oxytocin drip. Which data is most important for the nurse to monitor? C) Intensity, interval, and length of contractions 12. The nurse is caring for a newborn who is 18inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10inches. Based on these physical findings, assessment for which condition has the highest priority? A) Hyperthermia 13. .Assessment findings of a 3-hour old newborn include: axillary temperature of 97.7 F,heart rate of 140 beats/min with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement? d. place the infant under the radiant warmer 14.Which type of anesthesia, used with a client in labor, produces a loss of sensation onlyto the vagina and perineum? a. pudendal block 15.A new mother asks the nurse about an area of swelling on her baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond? a. that is called a caput succedaneum. it will absorb and cause no problems* 16.A 5-day old infant with a serum bilirubin of 19 mg/dl is being discharged from the hospital. Which instruction should the nurse include in the discharge teaching plan? b. monitor skin and eyes for yellow tinge 17.The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/min, respiratory rate 16 breaths/min, andblood pressure 130/74. What action should the nurse implement? c. document the vital signs in the record 18.A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin E drug. How should the nurse respond? d. you may be at higher risk for having a spontaneous miscarriage * 19.A pregnant woman who is at 10-weeks’ gestation and is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with Down Syndrome. Which information should the nurse provide this client? d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used toidentify Down Syndrome * 20.A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, menopur) and HCG. Which side effect should the nurse tell the client to report immediately? c. nausea and vomiting 21.The HCP prescribes 10 units/L of oxytocin (Pitocin) via IV drip to augment a client’s labor because she is experiencing a prolonged active phase. Which finding would causethe nurse to immediately discontinue the oxytocin? d. contraction duration of 100 seconds * 22.The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority should the nurse address to ensure the newborn’s survival? c. heat loss 23.One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first? a. check the differential, since the WBC is normal for this client * 24.The nurse is performing a newborn assessment. Which symptom, if present in a newborn would indicate respiratory distress? b. flaring of the nares * 25. A client receiving epidural anesthesia begins to experience nausea and becomes paleand clammy. What intervention should the nurse implement first? Raise the foot of the bed 26. What is the normal bilirubin at 1 day old? A. The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. 27. How do we lower the levels if they are not severe? This infant's bilirubin is beginning to climb, and the infant should be monitored to prevent further complications. 28. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestationin preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor duringthe administration of this drug? Monitoring maternal and fetal heart rates is most important when terbutaline is beingadministered. 29. A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is thisnewborn likely to have exhibited? Choking, coughing, and cyanosis. 30. What does a child in respiratory distress look like? Apneic spells and grunting with prematurity or sepsis 32. What does a diaphragmatic hernia look like? Scaphoid abdomen and anorexia 33. A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot."Which explanation should the nurse give to this anxious client? There's a strong, tough membrane there to protect the baby so you need not be afraidto wash or comb his/her hair. 34. A client who is attending antepartum classes asks the nurse why her healthcareprovider has prescribed iron tablets. The nurse's response is based on what knowledge? It is difficult to consume 18 mg of additional iron by diet alone. 35. What is megaloblastic anemia caused by? Folic acid deficiency 36. A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? A home pregnancy test can be used right after your first missed period. 37. A 28-year-old client in active labor complains of cramps in her leg. What interventionshould the nurse implement? Extend the leg and dorsiflex the foot 38. When do the anterior and posterior fontanels close? anterior fontanel closes at 12 to 18 months and the posterior by the end of the secondmonth. 39. When assessing a client who is at 12-weeks gestation, the nurse recommends that sheand her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? 30 weeks gestation 40. The nurse should encourage the laboring client to begin pushing when? The cervix is completely dilated. 41. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? Have the client breathe into her cupped hands 42. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does notcross the suture line is a newborn variation known as... a cephalohematoma, caused by forceps trauma and may last up to 8 weeks. 43. When does the head return to its normal shape? 7-10 days 44. What did Nurse theorist Reva Rubin describe? The initial postpartum period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, andcloseness to families and the newborn. 45. A couple, concerned because the woman has not been able to conceive, is referred to ahealthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which post procedure complaint indicates that the fallopian tubes are patent? Shoulder pain 46. Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" Lying prone with a pillow on the abdomen 47. he nurse is caring for a newborn who is 18inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10inches. Based on these physical findings, assessment for which condition has the highest priority? a. Hyperthermia 48.A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client? a. When there is no significant vaginal bleeding. 49.A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, menopur), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately? c. Rapid increase in abdominal girth 50 .At 0600 while admitting a woman for a scheduled repeat Caesarean section (C-section),the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? a. Inform the anesthesia care provider 52.Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothersvaginal bleeding and finds that she has saturated two pads in 30minutes and has a boggy uterus. What action should the nurse implement first? a. Perform fundal massage until firm 53.AA client at 20 weeks gestation comes to antepartal clinic complaining of vaginal warts (human papilloma virus HPV). What information should the nurse provide this client? a. This client should be treated with acyclovir (Zovirax) 54..When planning care for a laboring client, the nurse identifies the need to withhold solidsfood while the client is in labored. What is the most important reasons for this nursing intervention? a. An increased risk of aspiration can occur if general anesthesia is needed 55.The parents of a male newborn have signed an informed consent for circumcision. which intervention should the nurse implement upon completion of the circumcision? a. Place petroleum gauze dressings on the site