Maternity HESI Case Study Questions with correct answers

Maternity HESI Case Study Questions with
correct answers

The nurse performs the first assessment upon the client's arrival to the
|| || || || || || || || || || ||



postpartum unit. Where would the nurse expect to palpate the fundus?
|| || || || || || || || || || ||




a. 3 cm above the umbilicus.
|| || || || ||




b. 1 cm above the umbilicus.
|| || || || ||




c. To the right of the umbilicus.
|| || || || || ||




d. Midway between the umbilicus and the pubic bone. - CORRECT ANSWERS
|| || || || || || || || || || ||




✔✔b. 1 cm above the umbilicus.
|| || || || || ||




For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus
|| || || || || || || || || || || || || || ||




Fifteen minutes after the initial assessment, the nurse finds the client
|| || || || || || || || || ||



disoriented and lying on her back in a pool of vaginal blood, with the sheets
|| || || || || || || || || || || || || || ||



beneath her saturated with blood.
|| || || || ||




Which action is most important for the nurse to implement immediately?
|| || || || || || || || || ||




a. Take vital signs
|| || ||

,b. Massage the fundus
|| || ||




c. Check the bladder
|| || ||




d. Increase the IV rate - CORRECT ANSWERS ✔✔b. Massage the fundus.
|| || || || || || || || || || ||




Since a boggy fundus is the most likely reason for this client's hemorrhaging,
|| || || || || || || || || || || ||



massing the fundus is the most important intervention. The nurse should
|| || || || || || || || || || ||



also call for assistance due to the amount of blood that has pooled under the
|| || || || || || || || || || || || || || ||



client.
||




what is the most likely reason a postpartum patient would be hemorrhaging?
|| || || || || || || || || || ||




- CORRECT ANSWERS ✔✔uterine atony (a "boggy" fundus)
|| || || || || || || ||




What should be assessed immediately after fundus is massaged and nurse has
|| || || || || || || || || || ||




called for help? - CORRECT ANSWERS ✔✔Assess for bladder distention
|| || || || || || || || || ||




--> The client is 2 hours post-delivery with an IV infusion at 125 mL/hour,
|| || || || || || || || || || || || ||



which can contribute to diuresis. A distended bladder impedes uterine
|| || || || || || || || || ||



contraction and contributes to excessive bleeding. After the fundus is
|| || || || || || || || || ||



massaged, the bladder should be checked for distention.
|| || || || || || || ||




When the nurse conducts a gestational age assessment, which findings may
|| || || || || || || || || ||



indicate postmaturity? (Select all that apply. One, some, or all options may be
|| || || || || || || || || || || || ||



correct.)
||




a. Testes descended, good rugae.
|| || || ||

,b. Formed ears with instant recall.
|| || || || ||




c. Peeling, parchment-like skin.
|| || ||




d. Thin with loose skin and little subcutaneous fat.
|| || || || || || || ||




e. Deep creases at the base of the toes extending to the heels. - CORRECT
|| || || || || || || || || || || || || ||




ANSWERS ✔✔c. d. and e.
|| || || || || ||




c. Peeling, parchment-like skin.
|| || ||




d. Thin with loose skin and little subcutaneous fat.
|| || || || || || || ||




--> Subcutaneous fat, which had been used for nourishment, is lost prior to
|| || || || || || || || || || || ||



birth. This results in the infant's low temperature.
|| || || || || || || ||




e. Deep creases at the base of the toes extending to the heels.
|| || || || || || || || || || || ||




--> Postterm infants develop deep creases on the feet, extending from the
|| || || || || || || || || || ||



base
||

, The infant has a reddish papular rash across his face. How should the nurse
|| || || || || || || || || || || || ||



respond when the client asks about the rash?
|| || || || || || || ||




a. Don't worry about it. This rash will go away in a couple of days.
|| || || || || || || || || || || || || ||




b. I see you are concerned, so I will call your pediatrician.
|| || || || || || || || || || ||




c. A newborn rash is very common, but it will disappear soon.
|| || || || || || || || || || ||




d. Good question. Let me take the infant's vital signs and examine him -
|| || || || || || || || || || || || ||




CORRECT ANSWERS ✔✔c. A newborn rash is very common, but it will
|| || || || || || || || || || || ||



disappear soon.
|| ||




--> The infant rash, erythema toxicum, is very common and usually
|| || || || || || || || || ||



disappears by the third day of life.
|| || || || || || ||




Which factor should alert the nurse to assess for the risk of jaundice? -
|| || || || || || || || || || || || ||




CORRECT ANSWERS ✔✔trauma at birth
|| || || || ||




what is a normal bilirubin range for a newborn? - CORRECT ANSWERS ✔✔5-
|| || || || || || || || || || || ||




6 mg/dL
||




Which instructions should the nurse include in the discharge planning
|| || || || || || || || ||



regarding the infant's jaundice?
|| || || ||




a. The phototherapy blanket is placed over the infant's clothing.
|| || || || || || || || ||