Maternity HESI 1 and 2 Test Bank | Questions with Answers - Latest Graded A+

Maternity HESI 1 and 2 Test Bank | Questions with Answers - Latest Graded A+. A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved? A decreased in respiratory rate from 24 to 16 Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.) 14. Urinary output must be monitored when administering magnesium sulfate and should be at least 30 ml per hour. (The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.) What is the therapeutic level of magnesium sulfate? The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl. What does it help prevent? helps prevent seizures What indicates toxic levels? 3 Respiratory rate below 12 indicates toxic effects. Urine output of less than 100 ml/4 hours Absent DTRs 15. Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take? Place woman in a lateral position The nurse should immediately turn the woman to a lateral position, place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it further decreases, the anesthesiologist/healthcare provider should be notified immediately. 16. A client at 28-weeks gestation calls the antepartum clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? 3 Come to the clinic today for an ultrasound Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound. 17. An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? Put the newborn to breast Putting the newborn to breast will help contract the uterus and prevent a postpartum hemorrhage--this intervention has the highest priority. 18. A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. To help preserve cardiac reserves, the woman may need to restrict her activities and complete bedrest is often prescribed. 19. The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? Gonorrhea Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmic neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. 20. The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? Between the time the temperature falls and rises. In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise is the best time for conception. The human ovum can be fertilized 16 to 24 hours after ovulation. 4 21. The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? Edema, basilar rales, and an irregular pulse This indicates cardiac decompensation and requires immediate intervention. 22. A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? Describe diet changes that can improve the management of her diabetes Diet modifications are effective in managing Type 2 diabetes during pregnancy and describing the necessary diet changes is the most important intervention for the nurse to implement with this client. 23. A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? Raise the foot of the bed These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the client is in a lateral position are also appropriate interventions, and then checking the patient’s blood pressure. 24. 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. 25. 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. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin. 26. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestation in 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 during the administration of this drug? Monitoring maternal and fetal heart rates is most important when terbutaline is being administered. Terbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors 5 (causing tachycardia, a side effect of the drug) and stimulation of beta 2 receptors (causing uterine relaxation, a desired effect of the drug). 27. 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 this newborn likely to have exhibited? Choking, coughing, and cyanosis. the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea. 28. What does a child in respiratory distress look like? Apneic spells and grunting with prematurity or sepsis 29. What does a diaphragmatic hernia look like? Scaphoid abdomen and anorexia 30. 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 afraid to wash or comb his/her hair. 31. A client who is attending antepartum classes asks the nurse why her healthcare provider 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. Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult so iron supplements are often recommended. 32. What is megaloblastic anemia caused by? folic acid deficiency 33. 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. Home urine tests are based on the chemical detection of human chorionic gonadotrophin, which begins to increase 6 to 8 days after conception and is best detected at 2 weeks’ gestation or immediately after the first missed period. 34. A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement? 6 Extend the leg and dorsiflex the foot Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) and putting the heel of the foot on the floor is the best means of relieving leg cramps. 35. A client at 30-weeks’ gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? Obtaining a urine analysis should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.