Hesi Specialty Maternity (questions and answers with rationales)

Hesi Specialty Maternity (questions and answers with rationales) Maternity 1. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client? A. Which symptom did you experience first? B. Are you eating large amounts of salty foods? C. Have you visited a foreign country recently? D. Do you have a history of rheumatic fever? Clients with a history of rheumatic fever (D) may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client's health history is a priority. (A) is not important. Salty foods (B) sometimes cause edema, but this client is experiencing additional cardiac symptoms. (C) assesses for possible exposure to microorganisms, but these symptoms are more indicative of a cardiovascular etiology. Points Earned: 1/1 Correct Answer: D Your Response: D 2. A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency room. C. Lie on your left side for about one hour and see if the bleeding stops. D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection. Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound (A). Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which IS life-threatening to the mother and fetus--then (B) would be appropriate. (C) does not take the symptoms seriously. The woman is not describing symptoms of a UTI (D). Points Earned: 1/1 Correct Answer: A Your Response: A 3. A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? A. Dehydration. B. Hyperstimulation. C. Galactorrhea. D. Fetal tachycardia. Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture, and fetal distress or demise. Dehydration (A) and galactorrhea (C) are not adverse effects associated with the administration of Pitocin. Fetal tachycardia (D) is an initial response to any stressor, including an increase in maternal temperature or intrauterine infection, but fetal decelerations indicate distress following tetanic contractions. Points Earned: 1/1 Correct Answer: B Your Response: B 4. When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) A. Mood swings. B. Panic attacks. C. Tearfulness. D. Decreased need for sleep. E. Disinterest in the infant. Correct choices are (A and C). "Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after delivery and include mood swings (A), tearfulness (C), feeling low, emotional, and fatigued. (B, D, and E) are more characteristic of postpartum depression that typically occurs 3 to 7 days later than postpartum blues. Points Earned: 1/2 Correct Answer: A, C Your Response: A, C, E 5. The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? A. Two vessels: one artery and one vein. B. Two vessels: two arteries and no veins. C. Three vessels: two arteries and one vein. D. Three vessels: two veins and one artery. The normal umbilical cord contains three vessels--two arteries and one vein (C). Fewer than three vessels correlates with various congenital anomalies, such as cardiac and renal anomalies. (A, B, and D) would constitute abnormal findings. Points Earned: 0/1 Correct Answer: C