HESI PN MATERNITY /HESI PN
MATERNAL NEWBORN ACTUAL
EXAM 3 VERSIONS AND STUDY
GUIDE COMPLETE 600 QUESTIONS
WITH DETAILED VERIFIED
ANSWERS /ALREADY GRADED A+
//BRAND NEW!!
VERSION A
A client who is 40 weeks into pregnancy is having a
vaginal examination at the clinic when the nurse notes a
sudden gush of yellowish, clear fluid from the vaginal
area. What should be the nurse’s first action?
a. Measure the fetal heart rate.
b. Monitor for uterine contractions.
c. Note the color and odor of the fluid.
d. Apply a dry pad under the client for her comfort.
A) Measure the fetal heart rate.
,Rationale:
When the amniotic sac ruptures, there is a risk that the
umbilical cord could prolapse, causing fetal bradycardia
and decreased blood supply to the fetus. The nurse
should measure the fetal heart rate immediately when
the amniotic sac ruptures. If the cord has prolapsed, the
fetus needs to be delivered immediately. It is important
to note the color and odor of the fluid for signs of
infection and to assess for uterine contractions;
however, the priority is assessing for a prolapsed cord by
assessing the fetal heart rate. Placing a dry pad under the
client is not a priority action.
A client who is in active labor requests pain relief
measures and prefers epidural anesthesia. Which action
should the nurse take when caring for this client?
(Select all that apply.)
a. Restrict oral and intravenous fluids for 2 hours prior
to the epidural.
b. Explain to the client she will be having a metal taste
in her mouth soon.
c. Monitor the client’s vital signs and immediately report
hypotension.
d. Assist the client into a prone position while the
epidural is administered.
,C) Monitor the client’s vital signs and immediately
report hypotension.
Rationale:
Hypotension is a common adverse effect of epidural
anesthesia. Intravenous fluids are infused to provide 500
to 1000 mL additional fluids prior to the procedure;
fluids are not restricted. A metallic taste in the mouth
indicates the medication has entered the bloodstream.
Immediately notify the health care provider if this
occurs. Epidural anesthesia is administered while the
client is in the sitting position.
The practical nurse (PN) is caring for a gravida 4, para 3,
with a history of rheumatic heart disease, admitted to the
antepartum unit in preterm labor at 32 weeks’ gestation.
Which assessment findings indicate the onset of cardiac
failure requiring immediate intervention?
a. Edema, adventitious lung sounds, and tachycardia
b. Increased urinary output and irregular heart rate
c. Shortness of breath, bradycardia, and hypertension
d. Regular heart rate and hypertension
A) Edema, adventitious lung sounds, and tachycardia
, Rationale:
Edema, adventitious lung sounds, and an irregular pulse
indicate cardiac decompensation and require immediate
intervention.
Just after delivery, a new mother tells the practical nurse
(PN) that breastfeeding was unsuccessful with the client’s
first child, but the client would like to try with this baby.
Which intervention should the PN implement first?
a. Assess the husband’s feelings about his wife’s decision
to breastfeed their baby.
b. Ask the client to describe why she was unsuccessful
with breastfeeding her last child.
c. Encourage the client 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.
D) Provide assistance to the mother to begin
breastfeeding as soon as possible after delivery.
Rationale:
Infants respond to breastfeeding best when feeding is
initiated in the active phase soon after delivery.
MATERNAL NEWBORN ACTUAL
EXAM 3 VERSIONS AND STUDY
GUIDE COMPLETE 600 QUESTIONS
WITH DETAILED VERIFIED
ANSWERS /ALREADY GRADED A+
//BRAND NEW!!
VERSION A
A client who is 40 weeks into pregnancy is having a
vaginal examination at the clinic when the nurse notes a
sudden gush of yellowish, clear fluid from the vaginal
area. What should be the nurse’s first action?
a. Measure the fetal heart rate.
b. Monitor for uterine contractions.
c. Note the color and odor of the fluid.
d. Apply a dry pad under the client for her comfort.
A) Measure the fetal heart rate.
,Rationale:
When the amniotic sac ruptures, there is a risk that the
umbilical cord could prolapse, causing fetal bradycardia
and decreased blood supply to the fetus. The nurse
should measure the fetal heart rate immediately when
the amniotic sac ruptures. If the cord has prolapsed, the
fetus needs to be delivered immediately. It is important
to note the color and odor of the fluid for signs of
infection and to assess for uterine contractions;
however, the priority is assessing for a prolapsed cord by
assessing the fetal heart rate. Placing a dry pad under the
client is not a priority action.
A client who is in active labor requests pain relief
measures and prefers epidural anesthesia. Which action
should the nurse take when caring for this client?
(Select all that apply.)
a. Restrict oral and intravenous fluids for 2 hours prior
to the epidural.
b. Explain to the client she will be having a metal taste
in her mouth soon.
c. Monitor the client’s vital signs and immediately report
hypotension.
d. Assist the client into a prone position while the
epidural is administered.
,C) Monitor the client’s vital signs and immediately
report hypotension.
Rationale:
Hypotension is a common adverse effect of epidural
anesthesia. Intravenous fluids are infused to provide 500
to 1000 mL additional fluids prior to the procedure;
fluids are not restricted. A metallic taste in the mouth
indicates the medication has entered the bloodstream.
Immediately notify the health care provider if this
occurs. Epidural anesthesia is administered while the
client is in the sitting position.
The practical nurse (PN) is caring for a gravida 4, para 3,
with a history of rheumatic heart disease, admitted to the
antepartum unit in preterm labor at 32 weeks’ gestation.
Which assessment findings indicate the onset of cardiac
failure requiring immediate intervention?
a. Edema, adventitious lung sounds, and tachycardia
b. Increased urinary output and irregular heart rate
c. Shortness of breath, bradycardia, and hypertension
d. Regular heart rate and hypertension
A) Edema, adventitious lung sounds, and tachycardia
, Rationale:
Edema, adventitious lung sounds, and an irregular pulse
indicate cardiac decompensation and require immediate
intervention.
Just after delivery, a new mother tells the practical nurse
(PN) that breastfeeding was unsuccessful with the client’s
first child, but the client would like to try with this baby.
Which intervention should the PN implement first?
a. Assess the husband’s feelings about his wife’s decision
to breastfeed their baby.
b. Ask the client to describe why she was unsuccessful
with breastfeeding her last child.
c. Encourage the client 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.
D) Provide assistance to the mother to begin
breastfeeding as soon as possible after delivery.
Rationale:
Infants respond to breastfeeding best when feeding is
initiated in the active phase soon after delivery.
