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PSD|8944820
HESI MATERNITY PEDS(100+QUESTIONS AND
ANSWERS)EXAM PRACTICE GUIDE/2024/.
• A 38-week primigravida who works as a secretary and sits at a
computer for 8 hours each day tells the nurse that her feet have
begun to swell. Which instruction would be most effective in
preventing pooling of blood in the lower extremities?
ANS ;Move about every hour
Pooling of blood in the lower extremities results from the
enlarged uterus exerting pressure on the pelvic veins. Moving
about every hour will straighten out the pelvic veins and
increase venous return.
• A 26-year-old, gravida 2, para 1 client is admitted to the hospital at
28-weeks gestation in preterm labor. She is given 3 doses of
terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her
labor contractions. The nurse plans to monitor for which primary
side effect of terbutaline sulfate?
ANS; Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug,
stimulates beta-adrenergic receptors in the uterine muscle to stop
contractions. The beta-adrenergic agonist properties of the drug
may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
• When do the anterior and posterior fontanels close?
ANS; anterior fontanel closes at 12 to 18 months and the
posterior by the end of the second month.
• When assessing a client who is at 12-weeks gestation, the
nurse recommends that she and her husband consider
attending childbirth preparation classes. When is the best time
for the couple to attend these classes?
ANS; 30 weeks gestation
, at 30 weeks gestation is closest (of the options) to the time
parents would be ready for such classes. Learning is facilitated
by an interested pupil! The couple is most interested in
childbirth toward the end of the pregnancy when they are
psychologically ready for the termination of the pregnancy, and
the birth of their child is an immediate concern.
• The nurse should encourage the laboring client to
begin pushing when...ANS; the cervix is completely
dilated.
Pushing begins with the second stage of labor, i.e., when the cervix
is completely dilated at 10 cm (C). If pushing begins before the
cervix is completely dilated the cervix
1
can become edematous and may never completely dilate,
necessitating an operative delivery. Many primigravida’s begin
active labor 100%and theneffacedproceed to dilate.
• The nurse instructs a laboring client to use accelerated-blow
breathing. The client begins to complain of tingling fingers and
dizziness. What action should the nurse take?
ANS; Have the client breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation
(blowing off too much carbon dioxide). Hyperventilation is
treated by retaining carbon dioxide. This can be facilitated by
breathing into a paper bag or cupped hands.
• Twenty-four hours after admission to the newborn nursery, a
full-term male infant develops localized edema on the right side
of his head. The nurse knows that, in the newborn, an
accumulation of blood between the periosteum and skull which
does not cross the suture line is a newborn variation known
as...
ANS; A cephalohematoma, caused by forceps trauma and may last up to 8
weeks.
Cephalohematoma, a slight abnormal variation of the newborn,
usually arises within the first 24 hours after delivery. Trauma from
, delivery causes capillary bleeding between the periosteum and the
skull.
• When does the head
return to its normal
shape?
ANS; 7-10 days
• What did Nurse theorist Reva Rubin describe?
ANS; The initial postpartum period as the "taking-in phase," which
is characterized by maternal reliance on others to satisfy the needs
for comfort, rest, nourishment, and closeness to families and the
newborn.
• A couple, concerned because the woman has not been able to
conceive, is referred to a healthcare provider for a fertility workup
and a hysterosalpingography is scheduled. Which post procedure
complaint indicates that the fallopian tubes are patent?
ANS; Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from
a sub diaphragmatic collection of peritoneal dye/gas.
• Which nursing intervention is most helpful in relieving postpartum
uterine contractions or "afterpains?"
ANS; Lying prone with a pillow on the abdomen
Lying prone keeps the fundus contracted and is especially useful
with multiparas, who commonly experience afterpains due to
lack of uterine tone.
• Which maternal behavior is the nurse most likely to see
when a new mother receives her infant for the first time?
ANS; Her arms and hands receive the infant and she then traces
the infant's profile with her fingertips.
, Attachment/bonding theory indicates that most mothers will
demonstrate behaviors described in during the first visit with the
newborn, which may be at delivery or later.
• A client at 32-weeks gestation is hospitalized with severe
pregnancy-induced hypertension (PIH), and magnesium
sulfate is prescribed to control the symptoms. Which
assessment finding indicates the therapeutic drug level has
been achieved?
ANS; A decreased in respiratory rate from 24 to 16
Magnesium sulfate, a CNS depressant, helps prevent seizures. A
decreased respiratory rate indicates that the drug is effective.
(Respiratory rate below 12 indicates toxic effects.)
• Urinary output must be monitored when administering
magnesium sulfate and should be at least 30 ml per hour. (The
therapeutic level of magnesium sulfate for a PIH client is 4.8 to
9.6 mg/dl.) What is the therapeutic level of magnesium sulfate?
ANS; The therapeutic level of magnesium sulfate for a
PIH client is 4.8 to 9.6 mg/dl. What does it help prevent?
helps prevent seizures
What indicates toxic levels? 3
Respiratory rate below 12
indicates toxic effects. Urine
output of less than 100 ml/4
hours
Absent DTRs
• Twenty minutes after a continuous epidural anesthetic is
administered, a laboring client's blood pressure drops from 120/80
to 90/60. What action should the nurse take?
ANS; Place woman in a lateral position
The nurse should immediately turn the woman to a lateral
position, place a pillow or wedge under the right hip to deflect
the uterus, increase the rate of the main line IV infusion, and
administer oxygen by face mask at 10-12 L/min. If the blood
pressure remains low, especially if it further decreases, the
anesthesiologist/healthcare provider should be notified
immediately.
PSD|8944820
HESI MATERNITY PEDS(100+QUESTIONS AND
ANSWERS)EXAM PRACTICE GUIDE/2024/.
• A 38-week primigravida who works as a secretary and sits at a
computer for 8 hours each day tells the nurse that her feet have
begun to swell. Which instruction would be most effective in
preventing pooling of blood in the lower extremities?
ANS ;Move about every hour
Pooling of blood in the lower extremities results from the
enlarged uterus exerting pressure on the pelvic veins. Moving
about every hour will straighten out the pelvic veins and
increase venous return.
• A 26-year-old, gravida 2, para 1 client is admitted to the hospital at
28-weeks gestation in preterm labor. She is given 3 doses of
terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her
labor contractions. The nurse plans to monitor for which primary
side effect of terbutaline sulfate?
ANS; Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug,
stimulates beta-adrenergic receptors in the uterine muscle to stop
contractions. The beta-adrenergic agonist properties of the drug
may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
• When do the anterior and posterior fontanels close?
ANS; anterior fontanel closes at 12 to 18 months and the
posterior by the end of the second month.
• When assessing a client who is at 12-weeks gestation, the
nurse recommends that she and her husband consider
attending childbirth preparation classes. When is the best time
for the couple to attend these classes?
ANS; 30 weeks gestation
, at 30 weeks gestation is closest (of the options) to the time
parents would be ready for such classes. Learning is facilitated
by an interested pupil! The couple is most interested in
childbirth toward the end of the pregnancy when they are
psychologically ready for the termination of the pregnancy, and
the birth of their child is an immediate concern.
• The nurse should encourage the laboring client to
begin pushing when...ANS; the cervix is completely
dilated.
Pushing begins with the second stage of labor, i.e., when the cervix
is completely dilated at 10 cm (C). If pushing begins before the
cervix is completely dilated the cervix
1
can become edematous and may never completely dilate,
necessitating an operative delivery. Many primigravida’s begin
active labor 100%and theneffacedproceed to dilate.
• The nurse instructs a laboring client to use accelerated-blow
breathing. The client begins to complain of tingling fingers and
dizziness. What action should the nurse take?
ANS; Have the client breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation
(blowing off too much carbon dioxide). Hyperventilation is
treated by retaining carbon dioxide. This can be facilitated by
breathing into a paper bag or cupped hands.
• Twenty-four hours after admission to the newborn nursery, a
full-term male infant develops localized edema on the right side
of his head. The nurse knows that, in the newborn, an
accumulation of blood between the periosteum and skull which
does not cross the suture line is a newborn variation known
as...
ANS; A cephalohematoma, caused by forceps trauma and may last up to 8
weeks.
Cephalohematoma, a slight abnormal variation of the newborn,
usually arises within the first 24 hours after delivery. Trauma from
, delivery causes capillary bleeding between the periosteum and the
skull.
• When does the head
return to its normal
shape?
ANS; 7-10 days
• What did Nurse theorist Reva Rubin describe?
ANS; The initial postpartum period as the "taking-in phase," which
is characterized by maternal reliance on others to satisfy the needs
for comfort, rest, nourishment, and closeness to families and the
newborn.
• A couple, concerned because the woman has not been able to
conceive, is referred to a healthcare provider for a fertility workup
and a hysterosalpingography is scheduled. Which post procedure
complaint indicates that the fallopian tubes are patent?
ANS; Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from
a sub diaphragmatic collection of peritoneal dye/gas.
• Which nursing intervention is most helpful in relieving postpartum
uterine contractions or "afterpains?"
ANS; Lying prone with a pillow on the abdomen
Lying prone keeps the fundus contracted and is especially useful
with multiparas, who commonly experience afterpains due to
lack of uterine tone.
• Which maternal behavior is the nurse most likely to see
when a new mother receives her infant for the first time?
ANS; Her arms and hands receive the infant and she then traces
the infant's profile with her fingertips.
, Attachment/bonding theory indicates that most mothers will
demonstrate behaviors described in during the first visit with the
newborn, which may be at delivery or later.
• A client at 32-weeks gestation is hospitalized with severe
pregnancy-induced hypertension (PIH), and magnesium
sulfate is prescribed to control the symptoms. Which
assessment finding indicates the therapeutic drug level has
been achieved?
ANS; A decreased in respiratory rate from 24 to 16
Magnesium sulfate, a CNS depressant, helps prevent seizures. A
decreased respiratory rate indicates that the drug is effective.
(Respiratory rate below 12 indicates toxic effects.)
• Urinary output must be monitored when administering
magnesium sulfate and should be at least 30 ml per hour. (The
therapeutic level of magnesium sulfate for a PIH client is 4.8 to
9.6 mg/dl.) What is the therapeutic level of magnesium sulfate?
ANS; The therapeutic level of magnesium sulfate for a
PIH client is 4.8 to 9.6 mg/dl. What does it help prevent?
helps prevent seizures
What indicates toxic levels? 3
Respiratory rate below 12
indicates toxic effects. Urine
output of less than 100 ml/4
hours
Absent DTRs
• Twenty minutes after a continuous epidural anesthetic is
administered, a laboring client's blood pressure drops from 120/80
to 90/60. What action should the nurse take?
ANS; Place woman in a lateral position
The nurse should immediately turn the woman to a lateral
position, place a pillow or wedge under the right hip to deflect
the uterus, increase the rate of the main line IV infusion, and
administer oxygen by face mask at 10-12 L/min. If the blood
pressure remains low, especially if it further decreases, the
anesthesiologist/healthcare provider should be notified
immediately.
