: Maternal & Child Health Nursing Care of the
Childbearing & Childrearing Family Page |1
HESI Maternal 1 & Child Health Nursing Care of
the Childbearing & Childrearing Family 9th
Edition By JoAnne Silbert-Flagg Test Bank
|GRADED A+| (EXAM READY)
(Solved) SCORE A
A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot."
Which explanation should the nurse give to this anxious client?
A. "Some care is required when touching the large soft area on top of your baby's head until
the bones fuse together."
P a g e 1 | 92
, : Maternal & Child Health Nursing Care of the
Childbearing & Childrearing Family Page |2
B. "That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching
the soft spot."
C. "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for
your baby."
D. "There's a strong, tough membrane there to protect the baby so you need not be afraid to
wash or comb his/her hair." –
Correct Answer :D. "There's a strong, tough membrane there to protect the baby so you
need not be afraid to wash or comb his/her hair."
This answer provides correct information and attempts to alleviate anxiety related to
knowledge deficit
A client who is attending antepartum classes asks the nurse why her healthcare provider has
prescribed iron tablets. The nurse's response is based on what knowledge?
A. Supplementary iron is more efficiently utilized during pregnancy
B. It is difficult to consume 18 mg of additional iron by diet alone
C. Iron absorption is decreased in the GI tract during pregnancy
D. Iron is needed to prevent megaloblastic anemia in the last trimester
- Correct Answer :B. It is difficult to consume 18 mg of additional iron by diet alone
It is difficult to consume 18 mg of additional iron by diet alone.
Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to
meet the demands of pregnancy is difficult so iron supplements are often recommended.
P a g e 2 | 92
, : Maternal & Child Health Nursing Care of the
Childbearing & Childrearing Family Page |3
A client in active labor complains of cramps in her leg. What intervention should the nurse
implement?
A. Ask if she takes a daily calcium tablet
B. Extend the leg and dorsiflex the foot
C. Lower the leg off the side of the bed
D. Elevate the leg above the heart –
Correct Answer :B. Extend the leg and dorsiflex the foot
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is
capable) (B), and putting the heel of the foot on the floor is the best means of relieving leg
cramps.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for
observation. She is contracting irregularly and demonstrates underlying uterine irritability.
Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data,
which intervention should the nurse implement first?
A. Provide oral hydration
B. Have a complete blood count (CBC) drawn
C. Obtain a specimen for urine analysis
D. Place the client on strict bedrest
- Correct Answer :C. Obtain a specimen for urine analysis
Obtaining a urine analysis should be done first because preterm clients with uterine irritability
and contractions are often suffering from a urinary tract infection, and this should be ruled
out first.
P a g e 3 | 92
, : Maternal & Child Health Nursing Care of the
Childbearing & Childrearing Family Page |4
A client in active labor is admitted with preeclampsia. Which assessment finding is most
significant in planning this client's care?
A. Patellar reflex 4+
B. Blood pressure 158/80
C. Four-hour urine output 240 ml
D. Respiration 12/minute –
Correct Answer :A. Patellar reflex 4+
A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is
an indication of an impending seizure.
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three
weeks. Which assessment finding indicates to the nurse that the drug is effective?
A. Slowly increasing urinary output over the last week
B. Respiratory rate changes from the 40s to the 60s
C. Changes in apical heart rate from the 180s to the 140s
D. Change in indirect bilirubin from 12mg/dl to 8 mg/dl –
Correct Answer :C. Changes in apical heart rate from the 180s to the 140s
Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in
an increase in RBCs. Since the body has not had to compensate for anemia with an increased
heart rate, changes in heart rate from high to normal is one indicator that Epogen is effective
P a g e 4 | 92
Childbearing & Childrearing Family Page |1
HESI Maternal 1 & Child Health Nursing Care of
the Childbearing & Childrearing Family 9th
Edition By JoAnne Silbert-Flagg Test Bank
|GRADED A+| (EXAM READY)
(Solved) SCORE A
A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot."
Which explanation should the nurse give to this anxious client?
A. "Some care is required when touching the large soft area on top of your baby's head until
the bones fuse together."
P a g e 1 | 92
, : Maternal & Child Health Nursing Care of the
Childbearing & Childrearing Family Page |2
B. "That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching
the soft spot."
C. "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for
your baby."
D. "There's a strong, tough membrane there to protect the baby so you need not be afraid to
wash or comb his/her hair." –
Correct Answer :D. "There's a strong, tough membrane there to protect the baby so you
need not be afraid to wash or comb his/her hair."
This answer provides correct information and attempts to alleviate anxiety related to
knowledge deficit
A client who is attending antepartum classes asks the nurse why her healthcare provider has
prescribed iron tablets. The nurse's response is based on what knowledge?
A. Supplementary iron is more efficiently utilized during pregnancy
B. It is difficult to consume 18 mg of additional iron by diet alone
C. Iron absorption is decreased in the GI tract during pregnancy
D. Iron is needed to prevent megaloblastic anemia in the last trimester
- Correct Answer :B. It is difficult to consume 18 mg of additional iron by diet alone
It is difficult to consume 18 mg of additional iron by diet alone.
Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to
meet the demands of pregnancy is difficult so iron supplements are often recommended.
P a g e 2 | 92
, : Maternal & Child Health Nursing Care of the
Childbearing & Childrearing Family Page |3
A client in active labor complains of cramps in her leg. What intervention should the nurse
implement?
A. Ask if she takes a daily calcium tablet
B. Extend the leg and dorsiflex the foot
C. Lower the leg off the side of the bed
D. Elevate the leg above the heart –
Correct Answer :B. Extend the leg and dorsiflex the foot
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is
capable) (B), and putting the heel of the foot on the floor is the best means of relieving leg
cramps.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for
observation. She is contracting irregularly and demonstrates underlying uterine irritability.
Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data,
which intervention should the nurse implement first?
A. Provide oral hydration
B. Have a complete blood count (CBC) drawn
C. Obtain a specimen for urine analysis
D. Place the client on strict bedrest
- Correct Answer :C. Obtain a specimen for urine analysis
Obtaining a urine analysis should be done first because preterm clients with uterine irritability
and contractions are often suffering from a urinary tract infection, and this should be ruled
out first.
P a g e 3 | 92
, : Maternal & Child Health Nursing Care of the
Childbearing & Childrearing Family Page |4
A client in active labor is admitted with preeclampsia. Which assessment finding is most
significant in planning this client's care?
A. Patellar reflex 4+
B. Blood pressure 158/80
C. Four-hour urine output 240 ml
D. Respiration 12/minute –
Correct Answer :A. Patellar reflex 4+
A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is
an indication of an impending seizure.
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three
weeks. Which assessment finding indicates to the nurse that the drug is effective?
A. Slowly increasing urinary output over the last week
B. Respiratory rate changes from the 40s to the 60s
C. Changes in apical heart rate from the 180s to the 140s
D. Change in indirect bilirubin from 12mg/dl to 8 mg/dl –
Correct Answer :C. Changes in apical heart rate from the 180s to the 140s
Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in
an increase in RBCs. Since the body has not had to compensate for anemia with an increased
heart rate, changes in heart rate from high to normal is one indicator that Epogen is effective
P a g e 4 | 92
