1
© lec_Bismark | Educational Resources
HESI 2 HEALTH ASSESSMENT FOR MED SURG
PRECONCEEPTION LABOR CARE
Q&A 100% VERIFIED 2026
The nurse is planning preconception care for a new female client. Which information
should the nurse provide the client?
Encourage healthy lifestyles for families desiring pregnancy. Rationale
Preconception care has an overall goal to prepare the client for a healthy pregnancy. It
begins with encouraging healthy lifestyle choises in the family and should focus on
measures to assist the client in reducing lifestyle variables that may increase the risk for
problems in pregnancy.
A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started on IV magnesium
sulfate after being diagnosed with severe preeclampsia. After determining the serum
magnesium level to be 15 mEq/L, the nurse should expect which of the following
manifestations in the client?
Respiratory distress. Rationale
The therapeutic level of magnesium sulfate is 4 to 7 mEq/L. ECG changes
occur at 5 to 10 mEq/L. Loss of reflexes is unavoidable at 8 to 12 mEq/L. At 15 mEq/L, the client may
experience respiratory distress. At 25 mEq/L, cardiac arrest may occur.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a
non-stress test indicated that the fetus is experiencing some difficulties in utero. Which
diagnostic test should the nurse prepare the client for additional information about fetal
status?
Biophysical profile (BPP).Rationale
A BPP (biophysical profile) provides data regarding fetal risk surveillance by examining 5
areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone
and heart rate. The client's gestation has progressed past the estimated date of
confinement, so the major concern is fetal well-being related to an aging placenta, not
screening for fetal anomalies.
()
, 2
© lec_Bismark | Educational Resources
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!"
The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated
and 75% effaced. What additional information is most important for the nurse to
obtain?
Date of last normal menstrual period. Rationale
Evaluating the gestation of the pregnancy takes priority due to the risks involved when the
fetus is preterm. If preterm labor is imminent and a reassuring fetal heart pattern is
assessed, the healthcare provider may attempt to prolong the pregnancy by administering
corticosteroids to mature the lungs of the fetus.
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside?
(Select all that apply.)
Select all that apply A sterile
glove.
An amnihook.
Lubricant. Rationale
A single sterile glove, an amnihook, and lubricant are the necessary equipment for
performing an amniotomy.
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor.
Before initiating this prescription, it is most important for the nurse to assess the client for
which condition?
Gestational diabetes. Rationale
The nurse should evaluate the client for gestational diabetes because terbutaline
(Brethine) increases blood glucose levels.
()
, 3
© lec_Bismark | Educational Resources
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?
Come to the clinic today for an ultrasound. Rationale
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.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while
her husband is screaming for someone to help his wife. Which intervention has the highest
priority?
Put the newborn to breast. Rationale
The most important intervention is placing the newborn to the mother's breast. This
action serves two purposes as it will help contract the uterus thus preventing a postpartum
hemorrhage and avoid infant "cold-stress" because skin to skin will maintain the infant's
thermoregulation.
A client receiving epidural anesthesia begins to experience nausea and becomes pale and
clammy. What intervention should the nurse implement first?
Raise the foot of the bed. Rationale
These symptoms are suggestive of hypotension which is a side effect of epidural
anesthesia. Raising the foot of the bed will increase venous return and provide blood
to the vital areas.
()
, 4
© lec_Bismark | Educational Resources
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The
nurse knows that the most likely presenting symptom for a pediatric client with AIDS is
a persistent cold. Rationale
Respiratory tract infections commonly occur in the pediatric population. However, the
child with AIDS has a decreased ability to defend the body against these infections and
often the presenting symptom of a child with AIDS is a persistent cold.The others are
symptoms of complications which may occur later in the disease process.
A multigravida client arrives at the labor and delivery unit and tell the nurse that her
"bag of water" has broken. The nurse identifies the presence of meconium fluid on the
perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What
action should the nurse implement next?
Complete a sterile vaginal exam. Rationale
A vaginal exam should be performed after the rupture of membranes to
determine the presence of a prolapsed cord.
A woman with Type 2 diabetes mellitus becomes pregnant, and her
oral hypoglycemic agents are discontinued. Which intervention is most important for
the nurse to implement?
Describe diet changes that can improve the management of her diabetes. Rationale
Diet modifications are effective in managing Type 2 diabetes during pregnancy, and
describing the necessary diet changes is the most important intervention for the nurse to
implement with this client.
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control
the symptoms. Which
()
© lec_Bismark | Educational Resources
HESI 2 HEALTH ASSESSMENT FOR MED SURG
PRECONCEEPTION LABOR CARE
Q&A 100% VERIFIED 2026
The nurse is planning preconception care for a new female client. Which information
should the nurse provide the client?
Encourage healthy lifestyles for families desiring pregnancy. Rationale
Preconception care has an overall goal to prepare the client for a healthy pregnancy. It
begins with encouraging healthy lifestyle choises in the family and should focus on
measures to assist the client in reducing lifestyle variables that may increase the risk for
problems in pregnancy.
A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started on IV magnesium
sulfate after being diagnosed with severe preeclampsia. After determining the serum
magnesium level to be 15 mEq/L, the nurse should expect which of the following
manifestations in the client?
Respiratory distress. Rationale
The therapeutic level of magnesium sulfate is 4 to 7 mEq/L. ECG changes
occur at 5 to 10 mEq/L. Loss of reflexes is unavoidable at 8 to 12 mEq/L. At 15 mEq/L, the client may
experience respiratory distress. At 25 mEq/L, cardiac arrest may occur.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a
non-stress test indicated that the fetus is experiencing some difficulties in utero. Which
diagnostic test should the nurse prepare the client for additional information about fetal
status?
Biophysical profile (BPP).Rationale
A BPP (biophysical profile) provides data regarding fetal risk surveillance by examining 5
areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone
and heart rate. The client's gestation has progressed past the estimated date of
confinement, so the major concern is fetal well-being related to an aging placenta, not
screening for fetal anomalies.
()
, 2
© lec_Bismark | Educational Resources
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!"
The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated
and 75% effaced. What additional information is most important for the nurse to
obtain?
Date of last normal menstrual period. Rationale
Evaluating the gestation of the pregnancy takes priority due to the risks involved when the
fetus is preterm. If preterm labor is imminent and a reassuring fetal heart pattern is
assessed, the healthcare provider may attempt to prolong the pregnancy by administering
corticosteroids to mature the lungs of the fetus.
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside?
(Select all that apply.)
Select all that apply A sterile
glove.
An amnihook.
Lubricant. Rationale
A single sterile glove, an amnihook, and lubricant are the necessary equipment for
performing an amniotomy.
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor.
Before initiating this prescription, it is most important for the nurse to assess the client for
which condition?
Gestational diabetes. Rationale
The nurse should evaluate the client for gestational diabetes because terbutaline
(Brethine) increases blood glucose levels.
()
, 3
© lec_Bismark | Educational Resources
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?
Come to the clinic today for an ultrasound. Rationale
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.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while
her husband is screaming for someone to help his wife. Which intervention has the highest
priority?
Put the newborn to breast. Rationale
The most important intervention is placing the newborn to the mother's breast. This
action serves two purposes as it will help contract the uterus thus preventing a postpartum
hemorrhage and avoid infant "cold-stress" because skin to skin will maintain the infant's
thermoregulation.
A client receiving epidural anesthesia begins to experience nausea and becomes pale and
clammy. What intervention should the nurse implement first?
Raise the foot of the bed. Rationale
These symptoms are suggestive of hypotension which is a side effect of epidural
anesthesia. Raising the foot of the bed will increase venous return and provide blood
to the vital areas.
()
, 4
© lec_Bismark | Educational Resources
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The
nurse knows that the most likely presenting symptom for a pediatric client with AIDS is
a persistent cold. Rationale
Respiratory tract infections commonly occur in the pediatric population. However, the
child with AIDS has a decreased ability to defend the body against these infections and
often the presenting symptom of a child with AIDS is a persistent cold.The others are
symptoms of complications which may occur later in the disease process.
A multigravida client arrives at the labor and delivery unit and tell the nurse that her
"bag of water" has broken. The nurse identifies the presence of meconium fluid on the
perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What
action should the nurse implement next?
Complete a sterile vaginal exam. Rationale
A vaginal exam should be performed after the rupture of membranes to
determine the presence of a prolapsed cord.
A woman with Type 2 diabetes mellitus becomes pregnant, and her
oral hypoglycemic agents are discontinued. Which intervention is most important for
the nurse to implement?
Describe diet changes that can improve the management of her diabetes. Rationale
Diet modifications are effective in managing Type 2 diabetes during pregnancy, and
describing the necessary diet changes is the most important intervention for the nurse to
implement with this client.
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control
the symptoms. Which
()
