hesi_maternity_2_test_bank

HESI MATERNITY
TEST BANK


Maternity Evolve Exam
1. AJnonstressJtestJisJperformed,JandJtheJphysicianJdocumentsJ“accelerationsJlastingJlessJthanJ15JsecondsJthr
oughoutJfetalJmovement.”JTheJnurseJinterpretsJtheseJfindingsJas:
A. Normal

B. Reactive

C. NonreactiveJCorrect

D. Inconclusive

Rationale:JAJreactiveJnonstressJtestJisJaJnormal,JorJnegative,JresultJandJindicatesJaJhealthyJfetus.JTheJresultJrequiresJtwoJorJmo
reJfetalJheartJrateJaccelerationsJofJatJleastJ15Jbeats/minJlastingJatJleastJ15JsecondsJfromJtheJbeginningJofJtheJaccelerationJtoJt
heJend,JinJassociationJwithJfetalJmovement,JduringJaJ20-minuteJperiod.JAJnonreactiveJtestJisJanJabnormalJtest,JshowingJnoJacce
lerationsJorJaccelerationsJofJlessJthanJ15Jbeats/minJorJlastingJlessJthanJ15JsecondsJduringJaJ40-JminuteJobservation.JAnJinconc
lusiveJresultJisJoneJthatJcannotJbeJinterpretedJbecauseJofJtheJpoorJqualityJofJtheJfetalJheartJrateJrecording.

Test-TakingJStrategy:JUseJtheJprocessJofJelimination.JEliminateJaJreactiveJnonstressJtestJandJaJnormalJnonstressJtestJfirstJbec
auseJtheyJareJcomparableJorJalike.JToJselectJfromJtheJremainingJoptions,JnoteJtheJrelationshipJbetweenJ“lessJthanJ15Jseconds
”JinJtheJquestionJandJ“nonreactive”JinJtheJcorrectJoption.JIfJyouJhadJdifficultyJansweringJthisJquestion,JreviewJtheJinterpretatio
nJofJnonstressJtestJresults.


2. AJnurseJcaringJforJaJclientJinJlaborJperformsJanJassessment.JTheJclientJisJhavingJconsistentJcontractionsJlessJthanJ2Jmi
nutesJapart.JTheJfetalJheartJrateJ(FHR)JisJ170Jbeats/min,JandJfetalJmonitoringJindicatesJaJpatternJofJdecreasedJvariability.JInJli
ghtJofJtheseJfindings,JtheJappropriateJnursingJactionJis:
A. ContactingJtheJphysicianJCorrect

B. DocumentingJtheJfindings

C. ContinuingJtoJmonitorJtheJclient

D. ReassuringJtheJclientJandJherJpartnerJthatJlaborJisJprogressingJnormally

, Rationale:JSignsJofJpotentialJcomplicationsJofJlaborJincludeJcontractionsJconsistentlyJlastingJ90JsecondsJorJlonger,Jcontractio
nsJconsistentlyJoccurringJ2JminutesJorJlessJapart,JfetalJbradycardia,Jtachycardia,JpersistentlyJdecreasedJvariability,JorJanJirreg
ularJFHR.JTheJnormalJFHRJisJ110JtoJ160Jbeats/min.JTherefore,JbecauseJtheJfindingJisJabnormal,JtheJphysicianJmustJbeJcontact
ed.JContinuingJtoJmonitorJtheJclientJdelaysJnecessaryJintervention.JReassuringJtheJclientJthatJlaborJisJprogressingJnormallyJisJi
ncorrect.JTheJnurseJwouldJdocumentJtheJdata,JactionsJtaken,JandJtheJclient’sJresponse,Jbut,JofJtheJoptionsJprovided,Jcontacti
ngJtheJphysicianJisJtheJmostJappropriate.

Test-TakingJStrategy:JUseJtheJprocessJofJeliminationJandJfocusJonJtheJdataJinJtheJquestion.JEliminateJtheJoptionsJthatJareJcom
parableJorJalikeJandJindicateJthatJtheJdataJinJtheJquestionJareJnormalJfindings.JReviewJnormalJassessmentJfindingsJduringJtheJ
laborJprocessJifJyouJhadJdifficultyJwithJthisJquestion.

3. AJstillbornJinfantJwasJdeliveredJaJfewJhoursJago.JAfterJtheJbirth,JtheJfamilyJremainsJtogether,JholdingJandJtouchingJtheJb
aby.JWhichJstatementJbyJtheJnurseJisJappropriate?
A. “IJknowJhowJyouJfeel.”

B. “ThisJmustJbeJhardJforJyou.”JCorrect

C. “NowJyouJhaveJanJangelJinJheaven.”

, D. “You’reJyoung.JYouJcanJhaveJotherJchildren.”

Rationale:JTherapeuticJcommunicationJhelpsJtheJmother,Jfather,JandJotherJfamilyJmembersJexpressJtheirJfeelingsJandJemotio
ns.J“ThisJmustJbeJhardJforJyou”JisJaJcaringJandJempatheticJresponse,JfocusedJonJfeelingsJandJencouragingJcommunication.JTh
eJotherJoptionsJareJnontherapeuticJandJmayJdevalueJtheJfamilyJmembers'Jfeelings.

Test-TakingJStrategy:JUseJyourJknowledgeJofJtherapeuticJcommunicationJtechniques.JTheJcorrectJoptionJisJtheJonlyJoptionJthat
JisJfocusedJonJtheJfamilyJmembers’Jfeelings.JReviewJtherapeuticJcommunicationJtechniquesJifJyouJhadJdifficultyJwithJthisJquest

on.

4. AJrubellaJantibodyJscreenJisJperformedJinJaJpregnantJclient,JandJtheJresultsJindicateJthatJtheJclientJisJnotJimmuneJtoJrubel
la.JTheJnurseJtellsJtheJclientJthat:
A. AJrubellaJvaccineJmustJbeJadministeredJimmediately

B. AJrubellaJvaccineJmustJbeJadministeredJafterJchildbirthJCorrect

C. SheJwillJnotJcontractJrubellaJifJsheJisJexposedJtoJtheJdisease

D. SheJdoesJnotJneedJtoJbeJconcernedJaboutJbeingJexposedJtoJrubella

Rationale:JAJprenatalJrubellaJantibodyJscreenJisJperformedJinJeveryJpregnantJwomanJtoJdetermineJwhetherJsheJisJimmuneJtoJru
bella,JwhichJcanJcauseJseriousJfetalJanomalies.JIfJsheJisJnotJimmune,JrubellaJvaccineJisJofferedJafterJchildbirthJtoJkeepJherJfromJc
ontractingJrubellaJduringJsubsequentJpregnancies.JTheJvaccineJisJaJliveJvirus,JandJdefectsJmightJoccurJinJtheJfetusJifJtheJvaccin
eJwereJadministeredJduringJpregnancyJorJifJtheJmotherJwereJtoJbecomeJpregnantJsoonJafterJitJwasJadministered.JAdministerin
gJaJrubellaJvaccineJimmediatelyJplacesJtheJfetusJatJrisk.JTellingJtheJclientJthatJsheJdoesJnotJneedJtoJbeJconcernedJaboutJbeingJe
xposedJtoJrubellaJisJincorrect,JbecauseJtheJpossibilityJofJexposure,JwhichJcouldJbeJharmfulJtoJtheJfetus,JdoesJexist.

Test-TakingJStrategy:JUseJtheJprocessJofJelimination.JEliminateJfirstJtheJoptionsJthatJareJcomparableJorJalikeJ(i.e.,JtheJclientJw
illJnotJacquireJrubellaJandJdoesJnotJneedJtoJbeJconcernedJaboutJexposure).JToJselectJfromJtheJremainingJoptions,JrecallJthatJrub
ellaJvaccineJisJaJliveJvirus;JthisJwillJdirectJyouJtoJtheJcorrectJoption.JReviewJrubellaJvaccineJandJitsJimplicationsJduringJpregnanc
yJifJyouJhadJdifficultyJwithJthisJquestion.


5. AJnurseJcaringJforJaJclientJinJtheJactiveJstageJofJlaborJassessesJtheJfetalJstatusJandJnotesJaJlateJdecelerationJonJtheJm
onitorJstrip.JInJlightJofJthisJfinding,JwhichJnursingJactionJisJtheJpriority?
A. DocumentingJtheJfinding

B. PreparingJforJimmediateJbirth

C. AdministeringJoxygenJbyJwayJofJfaceJmaskJCorrect

D. IncreasingJtheJrateJofJtheJoxytocinJ(Pitocin)Jinfusion

Rationale:JLateJdecelerationsJareJaJresultJofJuteroplacentalJinsufficiencyJstemmingJfromJdecreasedJbloodJflowJandJoxygenJtran
sferJtoJtheJfetusJduringJuterineJcontractions.JThisJcausesJhypoxemia;JthereforeJoxygenJisJnecessary,JmakingJtheJadministratio
nJofJoxygenJtheJcorrectJchoice.JLateJdecelerationsJareJconsideredJanJominousJsignJbutJdoJnotJnecessarilyJrequireJimmediateJbi
rthJofJtheJbaby.JTheJoxytocinJinfusionJshouldJbeJdiscontinuedJwhenJaJlateJdecelerationJisJnoted.JTheJoxytocinJwouldJcauseJfurt
herJhypoxemia,JbecauseJtheJmedicationJstimulatesJcontractions,JleadingJtoJincreasedJuteroplacentalJinsufficiency.JAlthoughJth
eJfindingJneedsJtoJbeJdocumented,JdocumentationJisJnotJtheJpriorityJactionJinJthisJsituation.

Test-TakingJStrategy:JNoteJtheJstrategicJwordJ“priority”JinJtheJquestion.JUseJyourJknowledgeJofJtheJABCsJ—Jairway,

, breathing,JandJcirculationJ—
JtoJanswerJtheJquestion.JThisJwillJdirectJyouJtoJtheJcorrectJoption,JtheJoneJthatJaddressesJoxygen.JReviewJcontentJonJlateJdecele

rationsJifJyouJhadJdifficultyJwithJthisJquestion.
6. AJnurseJprovidesJinstructionsJregardingJpostpartumJexercisesJtoJaJclientJwhoJhasJdeliveredJaJnewbornJvaginally.JTheJ
nurseJtellsJtheJclientJthat:
A. TheJexercisesJshouldJbeJdelayedJforJ1JmonthJtoJallowJhealing

B. PerformingJsuchJexercisesJinJtheJpostpartumJperiodJmayJresultJinJstressJurinaryJincontinence

C. AlternatingJcontractionJandJrelaxationJofJtheJmusclesJofJtheJperinealJareaJshouldJbeJpracticedJCorrect

D. AbdominalJexercisesJwillJbeJstartedJwhileJtheJclientJisJinJtheJhospitalJasJaJmeansJofJevaluatingJtolerance
Rationale:JPostpartumJexercisesJmayJbeJstartedJsoonJafterJbirth,JalthoughJtheJwomanJshouldJbeJencouragedJtoJbeginJwithJsimp
leJexercisesJandJgraduallyJprogressJtoJmoreJstrenuousJones.JAbdominalJexercisesJareJpostponedJuntilJapproximatelyJ4JweeksJ
afterJaJcesareanJbirth.JKegelJexercisesJ(alternatedJcontractionJandJrelaxationJofJtheJmusclesJofJtheJperinealJarea)JareJextremel
yJimportantJinJstrengtheningJtheJmuscleJtoneJofJtheJperinealJareaJafterJvaginalJbirth.JKegelJexercisesJhelpJrestoreJtheJmuscleJt
oneJthatJisJoftenJlostJasJpelvicJtissuesJareJstretchedJandJtornJduringJpregnancyJandJbirth.JWomenJwhoJmaintainJmuscleJstrength
JmayJbenefitJyearsJlater,JexperiencingJcontinuedJurinaryJcontinence.




Test-TakingJStrategy:JUseJtheJprocessJofJelimination.JNoteJtheJrelationshipJbetweenJtheJwordJ“vaginally”JinJtheJquestionJandJ
“perinealJarea”JinJtheJcorrectJoption.JReviewJtheJpurposeJandJbenefitJofJKegelJexercisesJifJyouJhadJdifficultyJwithJthisJquestion.


7. AJclientJinJtheJfirstJtrimesterJofJpregnancyJarrivesJatJtheJclinicJandJreportsJthatJsheJhasJbeenJexperiencingJvaginalJblee
ding.JThreatenedJabortionJisJsuspected,JandJtheJnurseJprovidesJinstructionsJtoJtheJclientJregardingJcare.JWhichJstatementJb
yJtheJclientJindicatesJtheJneedJforJfurtherJinstruction?
A. “IJneedJtoJstayJinJbedJforJtheJrestJofJmyJpregnancy.”JCorrect

B. “IJneedJtoJavoidJhavingJsexJuntilJtheJbleedingJhasJstopped.”

C. “IJneedJtoJwatchJforJstuffJthatJlooksJlikeJtissueJcomingJfromJmyJvagina.”

D. “IJneedJtoJcountJtheJnumberJofJperinealJpadsJthatJIJuseJeachJdayJandJmakeJaJnoteJofJtheJamountJandJcolorJofJbloodJonJ

eachJpad.”
Rationale:JStrictJbedJrestJthroughoutJtheJremainderJofJtheJpregnancyJisJnotJrequired.JTheJwomanJisJadvisedJtoJcurtailJsexu
alJactivitiesJuntilJbleedingJhasJceasedJandJforJ2JweeksJafterJtheJlastJevidenceJofJbleeding,JasJrecommendedJbyJtheJphysicianJ
orJnurse-midwife.JTheJwomanJisJinstructedJtoJcountJtheJperinealJpadsJsheJusesJeachJdayJandJtoJnoteJtheJquantityJandJcolorJ
ofJbloodJonJeachJpad.JTheJwomanJshouldJalsoJwatchJforJtheJevidenceJofJtheJpassageJofJtissue.

Test-TakingJStrategy:JUseJtheJprocessJofJelimination.JNoteJtheJstrategicJwordsJ“needJforJfurtherJinstruction”JinJtheJquestion,J
whichJindicateJaJnegativeJeventJqueryJandJtheJneedJtoJselectJtheJincorrectJclientJstatement.JNotingJtheJwordsJ“stayJinJbedJforJth
eJrestJofJmyJpregnancy”JwillJdirectJyouJtoJthisJoption.JReviewJtherapeuticJmanagementJforJthreatenedJabortionJifJyouJhadJdifficul
tyJwithJthisJquestion.

8. AJnurseJisJassessingJtheJrespiratoryJrateJofJaJnewborn.JWhichJfindingJwouldJtheJnurseJdocumentJasJnormal?
A. 20Jbreaths/min

B. 25Jbreaths/min