HESI NCLEX RN COMPREHENSIVE
REVIEW (MATERNITY) 100% ACCURATE
ANSWERS.
An expectant father tells the nurse he fears that his wife "is losing her
mind." He states that she is constantly rubbing her abdomen and talking to
the baby and that she actually reprimands the baby when it moves too
much. Which recommendation should the nurse make to this expectant
father?
A. Suggest that his wife seek professional counseling to deal with her
symptoms.
B. Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D. Reassure him that normal maternal-fetal bonding is occurring. - CorreCt
Answers -D
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not
reflect ambivalence. No intervention is needed. Quickening, the first
perception of fetal movement, occurs at 17 to 20 weeks of gestation and
begins a new phase of prenatal bonding during the second trimester.
Options A and C are not necessary because the behaviors displayed are
normal.
The nurse calls a client who is 4 days postpartum to follow up about her
transition with her newborn son at home. The woman tells the nurse, "I
don't know what is wrong. I love my son, but I feel so let down. I seem to
cry for no reason!" Which adjustment phase should the nurse determine
the client is experiencing - CorreCt Answers -B
,Rationale:
During the postpartum period, when serum hormone levels fall, women are
emotionally labile, often crying easily for no apparent reason. This phase is
commonly called postpartum blues, which peaks around the fifth
postpartum day. The taking-in phase is the period following birth when the
mother focuses on her own psychological needs; typically, this period lasts
for 24 hours. Crying is not a maladaptive attachment response. It indicates
a normal physical and emotional response. The letting-go phase is when the
mother sees the child as a separate individual.
The nurse is counseling a client who wants to become pregnant. She tells
the nurse that she has a 36-day menstrual cycle and the first day of her last
menstrual period was January 8. When will the client's next fertile period
occur?
A. January 14 to 15
B. January 22 to 23
C. January 29 to 30
D. February 6 to 7 - CorreCt Answers -C
Rationale:
This client can expect her next period to begin 36 days from the first day of
her last menstrual period. Her next period would begin on February 12.
Ovulation occurs 14 days before the first day of the menstrual period. The
client can expect ovulation to occur January 29 to 30. Options A, B, and D
are incorrect.
A client at 30 weeks of gestation is on bed rest at home because of increased
blood pressure. The home health nurse has taught her how to take her own
blood pressure and gave her parameters to judge a significant increase in
,blood pressure. When the client calls the clinic complaining of indigestion,
which instruction should the nurse provide?
A. Lie on your left side and call 911 for emergency assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now, and if it is seriously elevated, go to the
hospital.
D. See your health care provider to obtain a prescription for a histamine
blocking agent. - CorreCt Answers -C
Rationale:
Checking the blood pressure for an elevation is the best instruction to give
at this time. A blood pressure exceeding 140/90 mm Hg is indicative of
preeclampsia. Epigastric pain can be a sign of an impending seizure
(eclampsia), a life-threatening complication of gestational hypertension.
Additional data are needed to confirm an emergency situation as described
in option A. Options B and D ignore the threat to client safety posed by a
significant increase in blood pressure.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and
reports that her lochia is getting lighter in color. Which action should the
nurse take?
A. Instruct the client to go to the emergency room.
B. Recommend vaginal douching.
C. Explain this is a normal finding.
D. Determine if ovulation has occurred. - CorreCt Answers -C
Rationale:
, The client is describing lochia serosa, a normal change in the lochial flow.
Options A, B, and D are not recommended for this normal finding.
Just after delivery, a new mother tells the nurse, "I was unsuccessful
breastfeeding my first child, but I would like to try with this baby." Which
intervention should the nurse implement first?
A. Assess the husband's feelings about his wife's decision to breastfeed their
baby.
B. Ask the woman to describe why she was unsuccessful with breastfeeding
her last child.
C. Encourage the woman to develop a positive attitude about breastfeeding
to help ensure success.
D. Provide assistance to the mother to begin breastfeeding as soon as
possible after delivery. - CorreCt Answers -D
Rationale:
Infants respond to breastfeeding best when feeding is initiated in the active
phase soon after delivery. Options A and B might provide interesting data,
but gathering this information is not as important as providing support and
instructions to the new mother. Although option C is also true, this
response by the nurse might seem judgmental to a new mother.
A 25-year-old client has a positive pregnancy test. One year ago she had a
spontaneous abortion at 3 months of gestation. Which is the correct
description of this client that should be documented in the medical record?
A. Gravida 1, para 0
B. Gravida 1, para 1
REVIEW (MATERNITY) 100% ACCURATE
ANSWERS.
An expectant father tells the nurse he fears that his wife "is losing her
mind." He states that she is constantly rubbing her abdomen and talking to
the baby and that she actually reprimands the baby when it moves too
much. Which recommendation should the nurse make to this expectant
father?
A. Suggest that his wife seek professional counseling to deal with her
symptoms.
B. Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D. Reassure him that normal maternal-fetal bonding is occurring. - CorreCt
Answers -D
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not
reflect ambivalence. No intervention is needed. Quickening, the first
perception of fetal movement, occurs at 17 to 20 weeks of gestation and
begins a new phase of prenatal bonding during the second trimester.
Options A and C are not necessary because the behaviors displayed are
normal.
The nurse calls a client who is 4 days postpartum to follow up about her
transition with her newborn son at home. The woman tells the nurse, "I
don't know what is wrong. I love my son, but I feel so let down. I seem to
cry for no reason!" Which adjustment phase should the nurse determine
the client is experiencing - CorreCt Answers -B
,Rationale:
During the postpartum period, when serum hormone levels fall, women are
emotionally labile, often crying easily for no apparent reason. This phase is
commonly called postpartum blues, which peaks around the fifth
postpartum day. The taking-in phase is the period following birth when the
mother focuses on her own psychological needs; typically, this period lasts
for 24 hours. Crying is not a maladaptive attachment response. It indicates
a normal physical and emotional response. The letting-go phase is when the
mother sees the child as a separate individual.
The nurse is counseling a client who wants to become pregnant. She tells
the nurse that she has a 36-day menstrual cycle and the first day of her last
menstrual period was January 8. When will the client's next fertile period
occur?
A. January 14 to 15
B. January 22 to 23
C. January 29 to 30
D. February 6 to 7 - CorreCt Answers -C
Rationale:
This client can expect her next period to begin 36 days from the first day of
her last menstrual period. Her next period would begin on February 12.
Ovulation occurs 14 days before the first day of the menstrual period. The
client can expect ovulation to occur January 29 to 30. Options A, B, and D
are incorrect.
A client at 30 weeks of gestation is on bed rest at home because of increased
blood pressure. The home health nurse has taught her how to take her own
blood pressure and gave her parameters to judge a significant increase in
,blood pressure. When the client calls the clinic complaining of indigestion,
which instruction should the nurse provide?
A. Lie on your left side and call 911 for emergency assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now, and if it is seriously elevated, go to the
hospital.
D. See your health care provider to obtain a prescription for a histamine
blocking agent. - CorreCt Answers -C
Rationale:
Checking the blood pressure for an elevation is the best instruction to give
at this time. A blood pressure exceeding 140/90 mm Hg is indicative of
preeclampsia. Epigastric pain can be a sign of an impending seizure
(eclampsia), a life-threatening complication of gestational hypertension.
Additional data are needed to confirm an emergency situation as described
in option A. Options B and D ignore the threat to client safety posed by a
significant increase in blood pressure.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and
reports that her lochia is getting lighter in color. Which action should the
nurse take?
A. Instruct the client to go to the emergency room.
B. Recommend vaginal douching.
C. Explain this is a normal finding.
D. Determine if ovulation has occurred. - CorreCt Answers -C
Rationale:
, The client is describing lochia serosa, a normal change in the lochial flow.
Options A, B, and D are not recommended for this normal finding.
Just after delivery, a new mother tells the nurse, "I was unsuccessful
breastfeeding my first child, but I would like to try with this baby." Which
intervention should the nurse implement first?
A. Assess the husband's feelings about his wife's decision to breastfeed their
baby.
B. Ask the woman to describe why she was unsuccessful with breastfeeding
her last child.
C. Encourage the woman to develop a positive attitude about breastfeeding
to help ensure success.
D. Provide assistance to the mother to begin breastfeeding as soon as
possible after delivery. - CorreCt Answers -D
Rationale:
Infants respond to breastfeeding best when feeding is initiated in the active
phase soon after delivery. Options A and B might provide interesting data,
but gathering this information is not as important as providing support and
instructions to the new mother. Although option C is also true, this
response by the nurse might seem judgmental to a new mother.
A 25-year-old client has a positive pregnancy test. One year ago she had a
spontaneous abortion at 3 months of gestation. Which is the correct
description of this client that should be documented in the medical record?
A. Gravida 1, para 0
B. Gravida 1, para 1
