MATERNITY HESI CASE STUDY QUESTIONS AND CORRECT VERIFIED ANSWERS

MATERNITY HESI CASE STUDY
QUESTIONS AND CORRECT VERIFIED
ANSWERS
TheA2nurseA2performsA2theA2firstA2assessmentA2uponA2theA2client'sA2arrivalA2toA2theA2post
partumA2unit.A2WhereA2wouldA2theA2nurseA2expectA2toA2palpateA2theA2fundus?

a.A23A2cmA2aboveA2theA2umbilicus.

b.A21A2cmA2aboveA2theA2umbilicus.

c.A2ToA2theA2rightA2ofA2theA2umbilicus.

d.A2MidwayA2betweenA2theA2umbilicusA2andA2theA2pubicA2bone.A2-A2Ans--
b.A21A2cmA2aboveA2theA2umbilicus.
ForA2theA2firstA212A2hours,A2theA2fundusA2shouldA2beA21A2toA22A2cmA2aboveA2theA2umbilicu
s

FifteenA2minutesA2afterA2theA2initialA2assessment,A2theA2nurseA2findsA2theA2clientA2disorien
tedA2andA2lyingA2onA2herA2backA2inA2aA2poolA2ofA2vaginalA2blood,A2withA2theA2sheetsA2bene
athA2herA2saturatedA2withA2blood.

WhichA2actionA2isA2mostA2importantA2forA2theA2nurseA2toA2implementA2immediately?

a.A2TakeA2vitalA2signs

b.A2MassageA2theA2fundus

c.A2CheckA2theA2bladder

d.A2IncreaseA2theA2IVA2rateA2-A2Ans--b.A2MassageA2theA2fundus.

SinceA2aA2boggyA2fundusA2isA2theA2mostA2likelyA2reasonA2forA2thisA2client'sA2hemorrhaging
,A2massingA2theA2fundusA2isA2theA2mostA2importantA2intervention.A2TheA2nurseA2shouldA2al
soA2callA2forA2assistanceA2dueA2toA2theA2amountA2ofA2bloodA2thatA2hasA2pooledA2underA2th
eA2client.

whatA2isA2theA2mostA2likelyA2reasonA2aA2postpartumA2patientA2wouldA2beA2hemorrhaging?
A2-A2Ans--uterineA2atonyA2(aA2"boggy"A2fundus)


WhatA2shouldA2beA2assessedA2immediatelyA2afterA2fundusA2isA2massagedA2andA2nurseA2h
asA2calledA2forA2help?A2-A2Ans--AssessA2forA2bladderA2distention

,-->A2TheA2clientA2isA22A2hoursA2post-deliveryA2withA2anA2IVA2infusionA2atA2125A2mL/
hour,A2whichA2canA2contributeA2toA2diuresis.A2AA2distendedA2bladderA2impedesA2uterineA2c
ontractionA2andA2contributesA2toA2excessiveA2bleeding.A2AfterA2theA2fundusA2isA2massage
d,A2theA2bladderA2shouldA2beA2checkedA2forA2distention.

WhenA2theA2nurseA2conductsA2aA2gestationalA2ageA2assessment,A2whichA2findingsA2mayA2
indicateA2postmaturity?
A2(SelectA2allA2thatA2apply.A2One,A2some,A2orA2allA2optionsA2mayA2beA2correct.)


a.A2TestesA2descended,A2goodA2rugae.

b.A2FormedA2earsA2withA2instantA2recall.

c.A2Peeling,A2parchment-likeA2skin.

d.A2ThinA2withA2looseA2skinA2andA2littleA2subcutaneousA2fat.

e.A2DeepA2creasesA2atA2theA2baseA2ofA2theA2toesA2extendingA2toA2theA2heels.A2-A2Ans--
c.A2d.A2andA2e.A2

c.A2Peeling,A2parchment-likeA2skin.


d.A2ThinA2withA2looseA2skinA2andA2littleA2subcutaneousA2fat.

--
>A2SubcutaneousA2fat,A2whichA2hadA2beenA2usedA2forA2nourishment,A2isA2lostA2priorA2toA2b
irth.A2ThisA2resultsA2inA2theA2infant'sA2lowA2temperature.


e.A2DeepA2creasesA2atA2theA2baseA2ofA2theA2toesA2extendingA2toA2theA2heels.

--
>A2PosttermA2infantsA2developA2deepA2creasesA2onA2theA2feet,A2extendingA2fromA2theA2ba
se

TheA2infantA2hasA2aA2reddishA2papularA2rashA2acrossA2hisA2face.A2HowA2shouldA2theA2nurs
eA2respondA2whenA2theA2clientA2asksA2aboutA2theA2rash?

a.A2Don'tA2worryA2aboutA2it.A2ThisA2rashA2willA2goA2awayA2inA2aA2coupleA2ofA2days.

b.A2IA2seeA2youA2areA2concerned,A2soA2IA2willA2callA2yourA2pediatrician.

c.A2AA2newbornA2rashA2isA2veryA2common,A2butA2itA2willA2disappearA2soon.

, d.A2GoodA2question.A2LetA2meA2takeA2theA2infant'sA2vitalA2signsA2andA2examineA2himA2-
A2Ans--c.A2AA2newbornA2rashA2isA2veryA2common,A2butA2itA2willA2disappearA2soon.


--
>A2TheA2infantA2rash,A2erythemaA2toxicum,A2isA2veryA2commonA2andA2usuallyA2disappears
A2byA2theA2thirdA2dayA2ofA2life.


WhichA2factorA2shouldA2alertA2theA2nurseA2toA2assessA2forA2theA2riskA2ofA2jaundice?A2-
A2Ans--traumaA2atA2birth


whatA2isA2aA2normalA2bilirubinA2rangeA2forA2aA2newborn?A2-A2Ans--5-6A2mg/dL

WhichA2instructionsA2shouldA2theA2nurseA2includeA2inA2theA2dischargeA2planningA2regardin
gA2theA2infant'sA2jaundice?

a.A2TheA2phototherapyA2blanketA2isA2placedA2overA2theA2infant'sA2clothing.

b.A2HoldingA2theA2infantA2doesA2notA2interruptA2theA2phototherapyA2process.

c.A2AA2phototherapyA2blanketA2isA2moreA2effectiveA2thanA2theA2overheadA2lights.

d.A2TheA2lengthA2ofA2timeA2requiredA2forA2phototherapyA2interventionA2isA2decreased.A2-
A2Ans--b.A2HoldingA2theA2infantA2doesA2notA2interruptA2theA2phototherapyA2process.


--
>A2AlthoughA2diapersA2canA2beA2worn,A2theA2blanketA2isA2placedA2nextA2toA2theA2skinA2onA2
theA2trunkA2ofA2theA2bodyA2toA2exposeA2asA2muchA2skinA2asA2possibleA2toA2theA2light.

--
>A2TheA2phototherapyA2blanketA2allowsA2theA2infantA2toA2beA2heldA2whileA2theA2processA2is
A2continued.


AA2clientA2inA2herA2firstA2trimesterA2isA2concernedA2aboutA2howA2weightA2gainA2willA2affectA
2herA2appearanceA2andA2questionsA2theA2nurseA2concerningA2dietaryA2restrictions.A2HowA
2muchA2weightA2gainA2shouldA2theA2nurseA2pointA2outA2willA2beA2safeA2forA2thisA2clientA2wit
hA2aA2lowA2BMI?A2-A2Ans--28A2toA240A2pounds

TheA2recommendationA2forA2averageA2weightA2gainA2isA225A2toA235A2lbsA2(11A2toA216A2kilo
grams).A2
TheA2womanA2whoA2isA2underweightA2withA2aA2lowA2BMIA2shouldA2gainA228A2toA240A2poun
dsA2(13A2toA218A2kilograms).A2
IndividualsA2withA2aA2highA2BMIA2shouldA2gainA215A2toA225A2poundsA2(7A2toA211A2kilogram
s).

TheA2nurseA2isA2counselingA2aA2clientA2withA2aA2BMIA2ofA223A2aboutA2weightA2gainA2during
A2pregnancy.A2TheA2nurseA2teachesA2theA2clientA2thatA2duringA2theA2secondA2andA2thirdA2tr