HESI PRACTICE CASE STUDIES EXAM WITH CORRECT ANSWERS.

HESI PRACTICE CASE STUDIES EXAM WITH CORRECT
ANSWERS




Ms. Stacy Myers is in active labor at 38 weeks gestation with an uncomplicated pregnancy. She is admitted to
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the birthing center on october 10th at 0830. After 9 hours of labor, Ms. Myers has a spontaneous vaginal
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delivery of an infant boy. - correct answer
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The nurse places the infant under a radiant warmer and starts to dry him quickly. What is the rationale for these
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actions?
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-heat production is increased through stimulation
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-convective heat loss from evaporation is reduced t t t t t t




-newborns in an incubator are more difficult to access than those in a radiant warmer
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-bonding is promoted by enhancing the infant's appearance - correct answer convective heat loss from
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evaporation is reduced t t




explanation: drying the infant quickly and placing him under a radiant warmer reduced heat loss through
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evaporation and radiation t t




Which action should the nurse take prior to drying the infant's back?
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-note if the infant has passed an meconium stool
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-observe the sacral area for possible mongolian spots
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-assess the amount and location of vernix caseosa
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-inspect the back for possible neurological defects - correct answer inspect the back for possible neurological
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defects

,explanation: to prevent harm while drying the newborn, the back should always be inspected for possible
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neurological defects, such as spinal bifida t t t t t




APGAR calculation - correct answer Heart rate:
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0: absent
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1: less than 100
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2: over 100
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Resp. rate:
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0: absent
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1: slow, weak cry
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2: good cry
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Muscle tone: t




0: flaccid
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1: some flexion
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2: well flexed
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Reflex irritability: t




0: no response
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1: grimace
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2: cry
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Color: t




0: blue, pale
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1: body pink, extremities blue
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2: completely pink
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, At 1 minute of age, the infant is alert and active, and has a strong cry. He has a heart rate of 172 and a respiratory
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rate of 50. The infant's arms and legs are flexed, the color of his body is pink, and the color of both feet is blue.
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The nurse continues a physical assessment of the infant looking for normal and abnormal findings. Which
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APGAR score should the nurse assign? - correct answer 9
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not a 10 b/c one point is deducted for acrocyanosis
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Upon inspection of the umbilical cord, which finding should the nurse report to the healthcare provider?
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-the cord is covered with Wharton's jelly
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-pulsations are felt at the base of the cord t t t t t t t t t




-one artery and one vein is present
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-the cord is glistening with a pearl-like color - correct answer one artery and one vein is present
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explanation: two arteries and one vein should be present t t t t t t t t




The Myer's baby's head is molded from the vaginal delivery. Upon seeing the baby Ms. Myers says, "Oh, he is so
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beautiful, but something is wrong with his head". t t t t t t t t




How should the nurse respond?t t t t




-No nothing is wrong with his head. He really is a beautiful boy.
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-Yes, it is misshaped, but we will should you how to change it over time
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-His head has been molded from delivery through the birth canal, which is normal.
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-I know you are concerned. Would you like to talk further with the HCP? - correct answer His head has been
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molded from delivery through the birth canal, which is normal.
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explanation: molding commonly occurs in babies delivered vaginally, and the head will become more t t t t t t t t t t t t t t




symmetrical over time t t




Ms. Myers is offered the opportunity to breast feed. After securing a comfortable position for herself and the
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baby, Ms. Myers puts the infant to her breast. The baby latches onto the nipple, and with some
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encouragement, he begins to nurse. After a time of family interaction, Ms. Myers is taken to the postpartum t t t t t t t t t t t t t t t t t t




unit, and the infant is transferred to the transition care nursery. - correct answer
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