Maternity HESI 1 2 Test Bank Summer 2021 Questions Answers Rationale study Guide

1. On iadmission ito ithe iprenatal iclinic, ia i23-year-old iwoman itells ithe inurse ithat iher ilast imenstrual iperiod ibegan ion iFebruary i15, iand ithat ipreviously iher iperiods iwere iregular. iHer ipregnancy itest iis ipositive. iThis client'si iexpected idate iof idelivery i(EDD) iis A) November i22. Feedback: iCORRECT B) November i8. Feedback: iINCORRECT C) i D) iOctober i22. Feedback: iINCORRECT Feedback: iINCORRECT (A) icorrectly iapplies iNägele’s irule ifor iestimating ithe idue idate iby icounting iback i3 imonths ifrom ithe ifirst iday ofi ithe ilast imenstrual iperiod i(January, iDecember, iNovember) iand iadding i7 idays i(15+7=22). Points iEarned: 0.0/1.0 Correct iAnswer(s): i A 2. Which iaction ishould ithe inurse iimplement iwhen ipreparing ito imeasure ithe ifundal iheight iof ia ipregnant client?i A) B) Request ithe iclient ilie ion iher ileft iside. Feedback: iINCORRECT C) Perform iLeopold’s imaneuvers ifirst. Feedback: iINCORRECT D) Give ithe iclient isome icold ijuice ito idrink. Feedback: iINCORRECT Feedback: iINCORRECT To iaccurately imeasure ithe ifundal iheight, ithe ibladder imust ibe iempty i(A) ito iavoid ielevation iof ithe iuterus. iFundal iheight iis inot imeasured iwith ithe iclient ilying ion iher iside i(B). iLeopold's imaneuvers iare iperformed ito assessi ifetal iposition iand ithe iexpected ilocation iof ithe ipoint iof imaximal iimpulse i(PMI) ifor ifetal iheart irate (C). iCold ijuice i(D) idoes inot iaffect ithe ifundal iheight imeasurement, ibut imay ibe igiven ito iarouse ithe ifetus iif thei ifetus iappears ito ibe isleeping iduring ia inon-stress itest. Points iEarned: 0.0/1.0 Correct iAnswer(s): i A 3. In ievaluating ithe irespiratory ieffort iof ia ione-hour-old iinfant iusing ithe iSilverman-Anderson iIndex, ithe inurse determinesi ithe iinfant ihas isynchronized ichest iand iabdominal imovement, ijust ivisible ilower ichest iretractions, justi ivisible ixiphoid iretractions, iminimal iand itransient inasal iflaring, iand ian iexpiratory igrunt iheard ionly ion iauscultation. iWhat iSilverman-Anderson iscore ishould ithe inurse iassign ito ithis iinfant? i(Enter inumeral ivalue ionly.) Feedback: iINCORRECT A iSilverman-Anderson iIndex ihas ifive icategories iwith iscores iof i0, i1, ior i2. iThe itotal iscore iranges ifrom i0 ito 10. Four iof ithe ithese iassessment ifindings ishould ireceive ia iscore iof i1, iand ithe i5th ifinding i(synchronized chesti iand iabdominal imovement) ireceives ia iscore iof i0. iTherefore, ithe itotal iscore iis i4. iA itotal iscore iof i0 imeans ithe iinfant ihas ino idyspnea, ia itotal iscore iof i10 iindicates imaximum irespiratory idistress. Points iEarned: 0.0/1.0 Correct iAnswer(s): i 4 4. Which imaternal ibehavior iis ithe inurse imost ilikely ito isee iwhen ia inew imother ireceives iher iinfant ifor ithe ifirst time?i A) She ieagerly ireaches ifor ithe iinfant, iundresses ithe iinfant, iand iexamines ithe iinfant icompletely. Feedback: iINCORRECT B) Her iarms iand ihands ireceive ithe iinfant iand ishe ithen itraces ithe iinfant's iprofile iwith iher ifingertips. Feedback: iCORRECT C) Her iarms iand ihands ireceive ithe iinfant iand ishe ithen icuddles ithe iinfant ito iher iown ibody. Feedback: iINCORRECT D) i Feedback: iINCORRECT Attachment/bonding itheory iindicates ithat imost imothers iwill idemonstrate ibehaviors idescribed iin i(B) iduring thei ifirst ivisit iwith ithe inewborn, iwhich imay ibe iat idelivery ior ilater. iAfter ithe ifirst ivisit, ithe imother imay iexhibit igreater iaffection isuch ias ieagerly ireaching, ihugging, ietc. i(A, iC, iand iD). Points iEarned: 0.0/1.0 Correct iAnswer(s): i B 5. A i35-year-old iprimigravida iclient iwith isevere ipreeclampsia iis ireceiving imagnesium isulfate ivia icontinuous iIV iinfusion. iWhich iassessment idata iindicates ito ithe inurse ithat ithe iclient iis iexperiencing imagnesium isulfatetoxicity? i A) Deep itendon ireflexes i2+. Feedback: iINCORRECT B) Blood ipressure i140/90. Feedback: iINCORRECT C) Respiratory irate i18/minute. Feedback: iINCORRECT D) Urine ioutput i90 iml/4 ihours. Feedback: iCORRECT Feedback: iINCORRECT Urine ioutputs iof iless ithan i100 iml/4 ihours i(D), iabsent iDTRs, iand ia irespiratory irate iof iless ithan i12 ibreaths/minute iare icardinal isigns iof imagnesium isulfate itoxicity. i(A, iB, iand iC) ido inot iindicate ia imagnesium sulfatei itoxicity. Points iEarned: 0.0/1.0 Correct iAnswer(s): i D 6. An iexpectant ifather itells ithe inurse ihe ifears ithat ihis iwife i"is ilosing iher imind." iHe istates ishe iis iconstantly irubbing iher iabdomen iand italking ito ithe ibaby, iand ithat ishe iactually ireprimands ithe ibaby iwhen iit imoves itoo much.i iWhat irecommendation ishould ithe inurse imake ito ithis iexpectant ifather? A) Reassure ihim ithat ithese iare inormal ireactions ito ipregnancy iand isuggest ithat ihe idiscuss ihis iconcerns with ithe ichildbirth ieducation inurse. Feedback: iINCORRECT B) Help ihim ito iunderstand ithat ihis iwife iis iexperiencing inormal isymptoms iof iambivalence iabout ithe pregnancy iand ino iaction iis ineeded. Feedback: iINCORRECT C) Ask ihim ito iobserve ihis iwife's ibehavior icarefully ifor ithe inext ifew iweeks iand ireport iany isimilar behavior ito ithe inurse iat ithe inext iprenatal ivisit. Feedback: iINCORRECT D) Let ihim iknow ithat ithese ibehaviors iare ipart iof inormal imaternal/fetal ibonding iwhich ioccur ionce ithe mother ifeels ifetal imovement. Feedback: iCORRECT Feedback: iINCORRECT These ibehaviors iare ipositive isigns iof imaternal/fetal ibonding i(D) iand ido inot ireflect iambivalence i(B). iNo interventioni iis ineeded. iQuickening, ithe ifirst iperception iof ifetal imovement, ioccurs iat i17 ito i20 iweeks igestation iand ibegins ia inew iphase iof iprenatal ibonding iduring ithe isecond itrimester. iAlthough i(A) iis inot iwrong, iit idismisses ithe ifather's iconcerns. i(C) iis inot iindicated. Points iEarned: 0.0/1.0 Correct iAnswer(s): i D 7. A ipregnant iclient itells ithe inurse ithat ithe ifirst iday iof iher ilast imenstrual iperiod iwas iAugust i2, i2006. iBased ion Nägele’si irule, iwhat iis ithe iestimated idate iof idelivery? A) iApril i25, i2007. Feedback: iINCORRECT