HESI RN Maternity Assignment Exam - Questions and Answers

HESI RN Maternity Assignment Exam - Questions and Answers A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action? -assess newborn reflexes for signs of neuro impairment -leave infant in the room with the mother to foster attachment -obtain serum glucose levels frequently while observing closely for signs of hypoglycemia -perform a gestational age assessment to determine if the infant is large for gestational age An infant who weighs 3.8 kg is delivered vaginally at 39 weeks gestation with a nuchal cord after a 30 minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide? -further assessment is indicated -petechiae occurs with forceps delivery -an increased blood volume causes broken blood vessels -pinpoint spots are benign and disappear within 48 hours Which finding for a client in labor at 41 weeks gestation requires additional assessment by the nurse? -cervix dilated 2 cm and 50% effaced -score of 8 on the biophysical profile -fetal heart rate of 116 bpm -one fetal movement noted in an hour A primigravida at 12 weeks gestation who just moved to the United States indicates she has not received any immunizations. Which Immunizations should the nurse administer at this time? (Select all that apply) A. Tetanus C. Diphtheria E. Hepatitis B A gravid client develops maternal hypotension following regional anesthesia. What interventions should the nurse implement? (Select all that apply) A. Administer oxygen B. Increase IV fluids E. Place the client in a lateral position F. Monitor fetal status A client at 29 weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? -amniocentesis -ultrasonography -chorionic villus sampling -maternal serum alpha-fetoprotein The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? -kidneys and renal function are not fully developed -warmth promotes sleep so the infant will grow quickly -a large body surface area favors heat loss to the environment -thick layer of subcut fat is inadequate for insulation The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? -ask mother why she won't look at infant -observe the mother for other attachment behaviors -examine the newborns eyes for ability to focus -recognize this as a common reaction in new mothers The nurse notes an irregular bluish hue on the sacral area of a 1 day old Hispanic infant. How should the nurse document this finding? -acrocyanosis -mongolian spots -erythema toxicum -harlequin sign An infant with hyperbilirubinaemia is receiving phototherapy. What intervention should the nurse implement? -maintain NPO -monitor temperature -apply skin lotion as prescribed -change t-shirt every 3 hours A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory distress, tahcycardia, and a cutaneous rash. What nursing intervention should be implemented first? -inform HCP -stop the transfusion -administer calcium gluconate -monitor VS electronically The nurse assesses a high risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What nursing action should be implemented? -place socks on infant -elevate feet 15 degrees -wrap feet loosely in prewired blanket -report findings to HCP What nursing action should be implemented when intermittently gavage-feeding a preterm infant? -allow formula to flow by gravity -avoid letting infant suck on tube -insert feeding tube through nares -apply steady pressure to syringe Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? -tactile stimulation -commercial warm packs -skin to skin contact with parent -oral sucrose and nonnutritive sucking The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37 weeks gestation. What nursing action should be implemented first? -provide tactile stimulation -administer flow by 100% oxygen -assess the functionality of the monitoring device -evaluate the newborns color and respirations What action should the nurse implement with the family when an infant is born with anencephaly?