Maternity HESI Study Grand Canyon University NSG 318
| QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+
The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and
grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the
Dinamap display. What action should the nurse implement?
1. Obtain a serum glucose level.
2. Give the infant medication for pain.
3. Feed the newborn 1 ounce of formula.
4. Request a genetic consultation. - answer :2. Give the infant medication for pain.
A cry face (or crying with the eyes squeezed or closed tightly), a rigid posture, and an increase in blood
pressure are indicative of pain in the neonate, so analgesia should be given for pain (B). The
symptoms of hypoglycemia (A) are jitteriness and mottling. The signs of hunger include rooting,
tongue extrusion and possibly crying (C). A high-pitched shrill cry is associated with neurologic and
genetic anomalies (D).
The nurse is assessing a 12-hour-old infant with a maternal history of frequent alcohol consumption
during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol
syndrome (FAS)?
1. An extra digit on the left hand.
2. Corneal clouding.
3. Flat nasal bridge.
4. Asymmetrical bulging fontanels. - answer :3. Flat nasal bridge.
,FAS is typically manifested by craniofacial anomalies, including short eyelid opening, flat midface or
flat nasal bridge (C), flat upper lip groove, thin upper lip, and microcephaly. (A, B and D) are not
usually associated with FAS.
A client states, "During the three months I've been pregnant, it seems like I have had to go to the
bathroom every five minutes." Which explanation should the nurse provide to this client?
1. The client may have a bladder or kidney infection.
2. Bladder capacity increases during pregnancy.
3. During pregnancy a woman is especially sensitive to body functions.
4. The growing uterus is putting pressure on the bladder. - answer :4. The growing uterus is putting
pressure on the bladder.
Urinary frequency is a normal discomfort (D) during the first trimester, when the enlarging uterus is
still low in the pelvis. It encroaches on the bladder, reducing its capacity. Although urinary frequency
is a symptom of bladder infection, it is usually accompanied by other symptoms such as burning on
urination, and a kidney infection is usually accompanied by pain and fever (A). Bladder capacity does
increase to about 1,500 ml during pregnancy (B), but increased capacity does not cause urinary
frequency. There is not enough data to reach the conclusion in (C).
The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and
identifies that the neonate's feet are blanched. What nursing action should be implemented?
1. Place socks on infant.
2. Elevate feet 15 degrees.
3. Wrap feet loosely in prewarmed blanket.
4. Report findings to the healthcare provider. - answer :4. Report findings to the healthcare provider.
Vasoconstriction of peripheral vessels, which can seriously impair circulation, is triggered by arterial
vasospasm caused by the presence of the catheter, the infusion of fluids, or the injection of
medication. Blanching of the buttocks, genitalia, or the legs or feet is an indication of vasospasm and
should be reported immediately to the healthcare provider (D). (A, B, and C) do not provide effective
resolution of this potentially serious complications.
,A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor,
the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to
baseline before each contraction ends. What action should the nurse implement?
1. Insert an internal monitor device.
2. Change the woman's position.
3. Discontinue the oxytocin infusion.
4. Document the finding in the client record. - answer :4. Document the finding in the client record.
Early FHR decelerations are a normal finding during active labor that occurs due to fetal head
compression, so the finding should be documented in the client record (D). Although the client's
status should be monitored continuously, this is a reassuring FHR pattern, so (A, B, and C) are not
indicated.
A multigravida client at 35-weeks gestation is diagnosed with pregnancy-induced hypertension (PIH).
Which symptom should the nurse instruct the client to report immediately?
1. Backache.
2. Constipation.
3. Blurred vision.
4. Increased urine output. - answer :3. Blurred vision.
Blurred vision, headache, visual changes, and epigastric discomfort are the most common symptoms
experienced by a client with PIH and may indicate impending seizures and should be reported.
A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of
magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider?
1. Blood pressure of 100/60 mm Hg.
2. Fetal heart rate of 120 to 125 beats/minute.
3. Contractions occurring every 30 minutes.
, 4. Respiratory rate of 11 breaths/minute. - answer :4. Respiratory rate of 11 breaths/minute.
A sign of magnesium toxicity is respiratory depression, so the client's respiration rate of 11
breaths/minute (D) should be reported to the healthcare provider. (A, B, and C) are expected findings
for a 36-week gestation client with PIH.
A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory
distress, tachycardia, and a cutaneous rash. What nursing intervention should be implemented first?
1. Inform the healthcare provider.
2. Stop the transfusion.
3. Administer calcium gluconate.
4. Monitor vital signs electronically. - answer :2. Stop the transfusion.
Exchange blood transfusion is a standard mode of therapy for treatment for severe
hyperbilirubinemia unresponsive to phototherapy and hydrops caused by Rh incompatibility. If the
neonate demonstrates signs of a blood transfusion reaction, such as tachycardia or bradycardia,
respiratory distress, dramatic change in blood pressure, temperature instability, and rash, the
transfusion should be stopped immediately (B). Then, the healthcare provider should be informed (A)
of the findings, and (C and D) implemented as needed.
A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history
includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which
designation is the most accurate summary of this client's obstetrical history?
1. 3-1-1-1-3.
2. 4-1-2-0-3.
3. 3-0-3-0-3.
4. 4-3-1-0-2. - answer :2. 4-1-2-0-3.
The client with 3 previous gravid experiences and this current pregnancy totals 4 gravid experiences,
and 1 term delivery (37-weeks or greater), 2 preterm deliveries (20 to 37 weeks, whether viable or not
| QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+
The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and
grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the
Dinamap display. What action should the nurse implement?
1. Obtain a serum glucose level.
2. Give the infant medication for pain.
3. Feed the newborn 1 ounce of formula.
4. Request a genetic consultation. - answer :2. Give the infant medication for pain.
A cry face (or crying with the eyes squeezed or closed tightly), a rigid posture, and an increase in blood
pressure are indicative of pain in the neonate, so analgesia should be given for pain (B). The
symptoms of hypoglycemia (A) are jitteriness and mottling. The signs of hunger include rooting,
tongue extrusion and possibly crying (C). A high-pitched shrill cry is associated with neurologic and
genetic anomalies (D).
The nurse is assessing a 12-hour-old infant with a maternal history of frequent alcohol consumption
during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol
syndrome (FAS)?
1. An extra digit on the left hand.
2. Corneal clouding.
3. Flat nasal bridge.
4. Asymmetrical bulging fontanels. - answer :3. Flat nasal bridge.
,FAS is typically manifested by craniofacial anomalies, including short eyelid opening, flat midface or
flat nasal bridge (C), flat upper lip groove, thin upper lip, and microcephaly. (A, B and D) are not
usually associated with FAS.
A client states, "During the three months I've been pregnant, it seems like I have had to go to the
bathroom every five minutes." Which explanation should the nurse provide to this client?
1. The client may have a bladder or kidney infection.
2. Bladder capacity increases during pregnancy.
3. During pregnancy a woman is especially sensitive to body functions.
4. The growing uterus is putting pressure on the bladder. - answer :4. The growing uterus is putting
pressure on the bladder.
Urinary frequency is a normal discomfort (D) during the first trimester, when the enlarging uterus is
still low in the pelvis. It encroaches on the bladder, reducing its capacity. Although urinary frequency
is a symptom of bladder infection, it is usually accompanied by other symptoms such as burning on
urination, and a kidney infection is usually accompanied by pain and fever (A). Bladder capacity does
increase to about 1,500 ml during pregnancy (B), but increased capacity does not cause urinary
frequency. There is not enough data to reach the conclusion in (C).
The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and
identifies that the neonate's feet are blanched. What nursing action should be implemented?
1. Place socks on infant.
2. Elevate feet 15 degrees.
3. Wrap feet loosely in prewarmed blanket.
4. Report findings to the healthcare provider. - answer :4. Report findings to the healthcare provider.
Vasoconstriction of peripheral vessels, which can seriously impair circulation, is triggered by arterial
vasospasm caused by the presence of the catheter, the infusion of fluids, or the injection of
medication. Blanching of the buttocks, genitalia, or the legs or feet is an indication of vasospasm and
should be reported immediately to the healthcare provider (D). (A, B, and C) do not provide effective
resolution of this potentially serious complications.
,A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor,
the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to
baseline before each contraction ends. What action should the nurse implement?
1. Insert an internal monitor device.
2. Change the woman's position.
3. Discontinue the oxytocin infusion.
4. Document the finding in the client record. - answer :4. Document the finding in the client record.
Early FHR decelerations are a normal finding during active labor that occurs due to fetal head
compression, so the finding should be documented in the client record (D). Although the client's
status should be monitored continuously, this is a reassuring FHR pattern, so (A, B, and C) are not
indicated.
A multigravida client at 35-weeks gestation is diagnosed with pregnancy-induced hypertension (PIH).
Which symptom should the nurse instruct the client to report immediately?
1. Backache.
2. Constipation.
3. Blurred vision.
4. Increased urine output. - answer :3. Blurred vision.
Blurred vision, headache, visual changes, and epigastric discomfort are the most common symptoms
experienced by a client with PIH and may indicate impending seizures and should be reported.
A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of
magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider?
1. Blood pressure of 100/60 mm Hg.
2. Fetal heart rate of 120 to 125 beats/minute.
3. Contractions occurring every 30 minutes.
, 4. Respiratory rate of 11 breaths/minute. - answer :4. Respiratory rate of 11 breaths/minute.
A sign of magnesium toxicity is respiratory depression, so the client's respiration rate of 11
breaths/minute (D) should be reported to the healthcare provider. (A, B, and C) are expected findings
for a 36-week gestation client with PIH.
A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory
distress, tachycardia, and a cutaneous rash. What nursing intervention should be implemented first?
1. Inform the healthcare provider.
2. Stop the transfusion.
3. Administer calcium gluconate.
4. Monitor vital signs electronically. - answer :2. Stop the transfusion.
Exchange blood transfusion is a standard mode of therapy for treatment for severe
hyperbilirubinemia unresponsive to phototherapy and hydrops caused by Rh incompatibility. If the
neonate demonstrates signs of a blood transfusion reaction, such as tachycardia or bradycardia,
respiratory distress, dramatic change in blood pressure, temperature instability, and rash, the
transfusion should be stopped immediately (B). Then, the healthcare provider should be informed (A)
of the findings, and (C and D) implemented as needed.
A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history
includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which
designation is the most accurate summary of this client's obstetrical history?
1. 3-1-1-1-3.
2. 4-1-2-0-3.
3. 3-0-3-0-3.
4. 4-3-1-0-2. - answer :2. 4-1-2-0-3.
The client with 3 previous gravid experiences and this current pregnancy totals 4 gravid experiences,
and 1 term delivery (37-weeks or greater), 2 preterm deliveries (20 to 37 weeks, whether viable or not
