Maternity HESI Test bank (combined red hesi
and other sources)
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An expectant father tells the nurse he fears that his wife is D) Reassure him that normal maternal-fetal bonding is occurring.
"losing her mind." He states that she is constantly rubbing
her abdomen and talking to the baby and that she Rationale:
actually reprimands the baby when it moves too much. These behaviors are positive signs of maternal-fetal bonding and do not reflect
Which recommendation should the nurse make to this ambivalence. No intervention is needed. Quickening, the first perception of fetal
expectant father? movement, occurs at 17 to 20 weeks of gestation and begins a new phase of
prenatal bonding during the second trimester. Options A and C are not necessary
A.Suggest that his wife seek professional counseling to because the behaviors displayed are normal.
deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the
pregnancy.
C. Ask him to report similar abnormal behaviors at the
next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is
occurring.
,The nurse is preparing a laboring client for an amniotomy. C. Fetal heart rate (FHR)
Immediately after the procedure is completed, it is most
important for the nurse to obtain which information? Rationale:
The FHR should be assessed before and after the procedure to detect changes
A.Maternal blood pressure that may indicate the presence of cord compression or prolapse. An amniotomy
(artificial rupture of membranes [AROM]) is used to stimulate labor when the
B.Maternal temperature condition of the cervix is favorable. The fluid should be assessed for color, odor,
and consistency. Option A should be assessed every 15 to 20 minutes during labor
C.Fetal heart rate (FHR) but is not specific for AROM. Option B is monitored hourly after the membranes
are ruptured to detect the development of amnionitis. Option D should be
D.White blood cell count (WBC) determined for all clients in labor.
A nurse receives a shift change report for a newborn who B. Skin color that is slightly jaundiced
is 12 hours post-vaginal delivery. In developing a plan of
care, the nurse should give the highest priority to which Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of
finding? bilirubin, which should be further evaluated in a newborn <24 hours old.
Acrocyanosis (blue color of the hands and feet) is a common finding in newborns;
A.Cyanosis of the hands and feet it occurs because the capillary system is immature. Milia are small white papules
present on the nose and chin that are caused by sebaceous gland blockage and
B.Skin color that is slightly jaundiced disappear in a few weeks. Small red patches on the cheeks and trunk are called
erythema toxicum neonatorum, a common finding in newborns.
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk
A breastfeeding postpartum client is diagnosed with A.Breastfeed the infant, ensuring that both breasts are completely emptied.
mastitis, and antibiotic therapy is prescribed. Which
instruction should the nurse provide to this client? Rationale:Mastitis, caused by plugged milk ducts, is related to breast
engorgement, and breastfeeding during mastitis facilitates the complete
A.Breastfeed the infant, ensuring that both breasts are emptying of engorged breasts, eliminating the pressure on the inflamed breast
completely emptied. tissue. Option B is less painful but does not facilitate complete emptying of the
breast tissue. Option C will not relieve the engorgement on the affected side.
B.Feed expressed breast milk to avoid the pain of the Option D will not decrease antibiotic effects on the infant.
infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the
mastitis subsides.
D.Dilute expressed breast milk with sterile water to
reduce the antibiotic effect on the infant.
, A 38-week primigravida who works as a secretary and sits C.Move about every hour.
at a computer 8 hours each day tells the nurse that her
feet have begun to swell. Which instruction will aid in the Rationale:
prevention of pooling of blood in the lower extremities? Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will relieve
A.Wear support stockings. pressure on the pelvic veins and increase venous return. Option A would increase
venous return from varicose veins in the lower extremities but would be of little
B.Reduce salt in the diet. help with swelling. Option B might be helpful with generalized edema but is not
specific for edematous lower extremities. Option D does not address venous
C.Move about every hour. return, and there is no indication in the question that constrictive clothing is a
problem.
D.Avoid constrictive clothing.
Twenty-four hours after admission to the newborn A.Cephalhematoma, which is caused by forceps trauma
nursery, a full-term male infant develops localized
swelling on the right side of his head. In a newborn, what Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually
is the most likely cause of this accumulation of blood arises within the first 24 hours after delivery. Trauma from delivery causes capillary
between the periosteum and skull that does not cross the bleeding between the periosteum and skull. Option C is a cranial distortion lasting
suture line? 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a
common variation of the newborn. Options B and D both involve intracranial
A.Cephalhematoma, which is caused by forceps trauma bleeding and could not be detected by physical assessment alone.
B.Subarachnoid hematoma, which requires immediate
drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong
damage
Prior to discharge, what instructions should the nurse C.Allow the cord to air-dry as much as possible.
give to parents regarding the newborn's umbilical cord
care at home? Rationale:Recent studies have indicated that air drying or plain water application
may be equal to or more effective than alcohol in the cord healing process.
A.Wash the cord frequently with mild soap and water. Options A, B, and D are incorrect because they promote moisture and increase
the potential for infection.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath
and other sources)
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Save
Students also studied
Flashcard sets Study guides
SimChart Hematologic Dysfunction SimChart Chest and Lungs Assessm... SimChart Health
15 terms 15 terms 15 terms 330 term
quizlette54464890 Preview quizlette54464890 Preview quizlette54464890 Preview Les
Terms in this set (186) Hide definitions
An expectant father tells the nurse he fears that his wife is D) Reassure him that normal maternal-fetal bonding is occurring.
"losing her mind." He states that she is constantly rubbing
her abdomen and talking to the baby and that she Rationale:
actually reprimands the baby when it moves too much. These behaviors are positive signs of maternal-fetal bonding and do not reflect
Which recommendation should the nurse make to this ambivalence. No intervention is needed. Quickening, the first perception of fetal
expectant father? movement, occurs at 17 to 20 weeks of gestation and begins a new phase of
prenatal bonding during the second trimester. Options A and C are not necessary
A.Suggest that his wife seek professional counseling to because the behaviors displayed are normal.
deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the
pregnancy.
C. Ask him to report similar abnormal behaviors at the
next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is
occurring.
,The nurse is preparing a laboring client for an amniotomy. C. Fetal heart rate (FHR)
Immediately after the procedure is completed, it is most
important for the nurse to obtain which information? Rationale:
The FHR should be assessed before and after the procedure to detect changes
A.Maternal blood pressure that may indicate the presence of cord compression or prolapse. An amniotomy
(artificial rupture of membranes [AROM]) is used to stimulate labor when the
B.Maternal temperature condition of the cervix is favorable. The fluid should be assessed for color, odor,
and consistency. Option A should be assessed every 15 to 20 minutes during labor
C.Fetal heart rate (FHR) but is not specific for AROM. Option B is monitored hourly after the membranes
are ruptured to detect the development of amnionitis. Option D should be
D.White blood cell count (WBC) determined for all clients in labor.
A nurse receives a shift change report for a newborn who B. Skin color that is slightly jaundiced
is 12 hours post-vaginal delivery. In developing a plan of
care, the nurse should give the highest priority to which Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of
finding? bilirubin, which should be further evaluated in a newborn <24 hours old.
Acrocyanosis (blue color of the hands and feet) is a common finding in newborns;
A.Cyanosis of the hands and feet it occurs because the capillary system is immature. Milia are small white papules
present on the nose and chin that are caused by sebaceous gland blockage and
B.Skin color that is slightly jaundiced disappear in a few weeks. Small red patches on the cheeks and trunk are called
erythema toxicum neonatorum, a common finding in newborns.
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk
A breastfeeding postpartum client is diagnosed with A.Breastfeed the infant, ensuring that both breasts are completely emptied.
mastitis, and antibiotic therapy is prescribed. Which
instruction should the nurse provide to this client? Rationale:Mastitis, caused by plugged milk ducts, is related to breast
engorgement, and breastfeeding during mastitis facilitates the complete
A.Breastfeed the infant, ensuring that both breasts are emptying of engorged breasts, eliminating the pressure on the inflamed breast
completely emptied. tissue. Option B is less painful but does not facilitate complete emptying of the
breast tissue. Option C will not relieve the engorgement on the affected side.
B.Feed expressed breast milk to avoid the pain of the Option D will not decrease antibiotic effects on the infant.
infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the
mastitis subsides.
D.Dilute expressed breast milk with sterile water to
reduce the antibiotic effect on the infant.
, A 38-week primigravida who works as a secretary and sits C.Move about every hour.
at a computer 8 hours each day tells the nurse that her
feet have begun to swell. Which instruction will aid in the Rationale:
prevention of pooling of blood in the lower extremities? Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will relieve
A.Wear support stockings. pressure on the pelvic veins and increase venous return. Option A would increase
venous return from varicose veins in the lower extremities but would be of little
B.Reduce salt in the diet. help with swelling. Option B might be helpful with generalized edema but is not
specific for edematous lower extremities. Option D does not address venous
C.Move about every hour. return, and there is no indication in the question that constrictive clothing is a
problem.
D.Avoid constrictive clothing.
Twenty-four hours after admission to the newborn A.Cephalhematoma, which is caused by forceps trauma
nursery, a full-term male infant develops localized
swelling on the right side of his head. In a newborn, what Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually
is the most likely cause of this accumulation of blood arises within the first 24 hours after delivery. Trauma from delivery causes capillary
between the periosteum and skull that does not cross the bleeding between the periosteum and skull. Option C is a cranial distortion lasting
suture line? 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a
common variation of the newborn. Options B and D both involve intracranial
A.Cephalhematoma, which is caused by forceps trauma bleeding and could not be detected by physical assessment alone.
B.Subarachnoid hematoma, which requires immediate
drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong
damage
Prior to discharge, what instructions should the nurse C.Allow the cord to air-dry as much as possible.
give to parents regarding the newborn's umbilical cord
care at home? Rationale:Recent studies have indicated that air drying or plain water application
may be equal to or more effective than alcohol in the cord healing process.
A.Wash the cord frequently with mild soap and water. Options A, B, and D are incorrect because they promote moisture and increase
the potential for infection.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath
