OB/Maternity HESI Assignment
Study online at https://quizlet.com/_e7rago
1. At 10-weeks gestation, a A. Uterine cramping
high-risk multiparous client
with a family history of Down Rationale
syndrome is admitted for obser-
The client should be monitored for 1 to 2 hours following
vation following a chorionic villi
the procedure for the occurrence of uterine cramping (A)
sampling (CVS) procedure. What
so that immediate intervention to decrease the risk of mis-
assessment finding requires im-
carriage can be initiated. This procedure (removal of a small
mediate intervention?
piece of tissue from the fetal portion of the placenta) may
Uterine cramping.
cause initiation of labor. (B) may occur at the puncture site
Abdominal tenderness.
if the procedure was done transabdominally. (C and D) are
Systolic blood pressure less
normal findings during in the first trimester.
than 100 mmHg.
Intermittent nausea.
Submit
2. A client states, "During the D. The growing uterus is putting pressure on the bladder.
three months I've been preg-
nant, it seems like I have had Rationale
to go to the bathroom every
Urinary frequency is a normal discomfort (D) during the
five minutes." Which explana-
first trimester, when the enlarging uterus is still low in the
tion should the nurse provide to
pelvis. It encroaches on the bladder, reducing its capacity.
this client?
Although urinary frequency is a symptom of bladder in-
he client may have a bladder or
fection, it is usually accompanied by other symptoms such
kidney infection.
as burning on urination, and a kidney infection is usually
Bladder capacity increases dur-
accompanied by pain and fever (A). Bladder capacity does
ing pregnancy.
increase to about 1,500 ml during pregnancy (B), but in-
During pregnancy, a woman
creased capacity does not cause urinary frequency. There is
is especially sensitive to body
not enough data to reach the conclusion in (C).
functions.
The growing uterus is putting
pressure on the bladder.
, OB/Maternity HESI Assignment
Study online at https://quizlet.com/_e7rago
3. The nurse assesses a male new- C. Assess the infant's blood glucose level
born and determines that he
has the following vital signs: Rationale
axillary temperature 95.1 F,
The nurse should first assess the infant's blood glucose level
heart rate 136 beats/minute,
(C), because the infant is displaying signs of hypothermia
and a respiratory rate 48
(normal newborn axillary temperature is 96 to 98 F) and
breaths/minute. Based on these
hypoglycemia may occur as glucose is metabolized in an
findings, which action should
effort to meet cellular energy demands. The infant's respi-
the nurse take first?
ratory and heart rates are within normal limits, so (A) is not a
Check the infant's arterial blood
priority. (B and D) would be implemented after information
gases.
regarding the blood sugar level has been obtained.
Notify the pediatrician of the in-
fant's vital signs.
Assess the infant's blood glu-
cose level.
Encourage the infant to take the
breast or sugar water.
Submit
4. An infant in respiratory distress B. Begin humidified oxygen via hood
is placed on pulse ox. The O2
sat is 85%. What is the priority Rationale
nursing intervention?
An oxygen saturation of less than 90% (normal oxygen
Evaluate the blood pH.
saturation is 96% to 98%) requires oxygen administration
Begin humidified oxygen via
(B). (A) is not necessary. (C) may utilize additional oxygen
hood.
and will not correct the problem. (D) is important because
Stimulate infant crying.
it may decrease energy use for respiratory effort, but it will
Place the infant under a radiant
not correct a low saturation level.
warmer.
5. When assessing a newborn in- C. Count the heart rate for at least one full minute
fant's heart rate, which tech-
, OB/Maternity HESI Assignment
Study online at https://quizlet.com/_e7rago
nique is most important for the Rationale
nurse to use?
Quiet the infant before count- It is most important for the nurse to count the heart rate for
ing the heart rate. at least one full minute (C) so that irregularities or murmurs
Listen at the apex of the heart. can be detected. (A) is not necessary for the heart rate to
Count the heart rate for at least be correctly auscultated. The heart rate can be heard clearly
one full minute. over any point of an infant's chest, not just (B). Immediately
Palpate the umbilical cord. after delivery, (D) will allow the nurse to assess the rate, but
(B) is the most accurate method of obtaining a newborn's
heart rate.
6. The nurse prepares to admin- B. Explore the mother's concerns about the infant receiving
ister an injection of vitamin K an injection of vitamin K.
to a newborn infant. The moth-
er tells the nurse, "Wait! I don't Rationale
want my baby to have a shot."
This mother's concerns should be explored (B) and any
Which response would be best
misconceptions cleared up before the vitamin K is injected.
for the nurse to make?
(A and C) are true but do not communicate the importance
Inform the mother that the in-
of vitamin K administration. Also, parents have the right
jection was prescribed by the
to refuse the injection by signing a refusal form. (D) is
healthcare provider.
providing false reassurance--all injections cause pain.
Explore the mother's concerns
about the infant receiving an in-
jection of vitamin K.
Explain that vitamin K is re-
quired by state law and compli-
ance is mandatory.
Remind the mother that all ba-
bies receive this shot and it is
relatively painless.
Submit
, OB/Maternity HESI Assignment
Study online at https://quizlet.com/_e7rago
7. The nurse is teaching a new A. Avoid alcohol because it is excreted in breast milk
mother about diet and breast-
feeding. Which instruction is Rationale
most important to include in the
Alcohol should be avoided while breastfeeding because,
teaching plan?
when consumed by the mother, it is excreted in breast
Avoid alcohol because it is ex-
milk (A). It also adversely effects the milk ejection reflex.
creted in breast milk.
While (B) may cause some gastric upset in some babies,
Avoid spicy foods to prevent in-
it does not cause colic. (C) should also be included in diet
fant colic.
teaching for a breastfeeding mother, but because it does
Increase caloric intake by ap-
not involve safety to the infant it does not have the same
proximately 500 calories/day.
degree of importance as (A). Recent research has shown
Double prenatal milk intake to
that infants receive very little Vitamin D via the breastmilk
improve Vitamin D transfer to
and some sources recommend Vitamin D supplementation
the infant.
in exclusively breastfed babies to prevent rickets.
8. Which nursing intervention D. Encourage early initiation of breast of formula feeding
best enhances maternal-infant
bonding during the fourth Rationale
stage of labor?
(D) is the best of the interventions listed to encourage
Brighten the lighting so the
maternal-infant bonding. (A, B, and C) are all methods of
mother can view the infant.
promoting maternal-infant bonding but are not usually as
Complete the newborn assess-
effective as initiating infant feeding.
ment as quickly as possible.
Provide positive reinforcement
for maternal care of the infant.
Encourage early initiation of
breast or formula feeding.
Submit
9. A client at 8-weeks gestation D. The heart develops in the third to fifth weeks after con-
asks the nurse about the risk ception.
Study online at https://quizlet.com/_e7rago
1. At 10-weeks gestation, a A. Uterine cramping
high-risk multiparous client
with a family history of Down Rationale
syndrome is admitted for obser-
The client should be monitored for 1 to 2 hours following
vation following a chorionic villi
the procedure for the occurrence of uterine cramping (A)
sampling (CVS) procedure. What
so that immediate intervention to decrease the risk of mis-
assessment finding requires im-
carriage can be initiated. This procedure (removal of a small
mediate intervention?
piece of tissue from the fetal portion of the placenta) may
Uterine cramping.
cause initiation of labor. (B) may occur at the puncture site
Abdominal tenderness.
if the procedure was done transabdominally. (C and D) are
Systolic blood pressure less
normal findings during in the first trimester.
than 100 mmHg.
Intermittent nausea.
Submit
2. A client states, "During the D. The growing uterus is putting pressure on the bladder.
three months I've been preg-
nant, it seems like I have had Rationale
to go to the bathroom every
Urinary frequency is a normal discomfort (D) during the
five minutes." Which explana-
first trimester, when the enlarging uterus is still low in the
tion should the nurse provide to
pelvis. It encroaches on the bladder, reducing its capacity.
this client?
Although urinary frequency is a symptom of bladder in-
he client may have a bladder or
fection, it is usually accompanied by other symptoms such
kidney infection.
as burning on urination, and a kidney infection is usually
Bladder capacity increases dur-
accompanied by pain and fever (A). Bladder capacity does
ing pregnancy.
increase to about 1,500 ml during pregnancy (B), but in-
During pregnancy, a woman
creased capacity does not cause urinary frequency. There is
is especially sensitive to body
not enough data to reach the conclusion in (C).
functions.
The growing uterus is putting
pressure on the bladder.
, OB/Maternity HESI Assignment
Study online at https://quizlet.com/_e7rago
3. The nurse assesses a male new- C. Assess the infant's blood glucose level
born and determines that he
has the following vital signs: Rationale
axillary temperature 95.1 F,
The nurse should first assess the infant's blood glucose level
heart rate 136 beats/minute,
(C), because the infant is displaying signs of hypothermia
and a respiratory rate 48
(normal newborn axillary temperature is 96 to 98 F) and
breaths/minute. Based on these
hypoglycemia may occur as glucose is metabolized in an
findings, which action should
effort to meet cellular energy demands. The infant's respi-
the nurse take first?
ratory and heart rates are within normal limits, so (A) is not a
Check the infant's arterial blood
priority. (B and D) would be implemented after information
gases.
regarding the blood sugar level has been obtained.
Notify the pediatrician of the in-
fant's vital signs.
Assess the infant's blood glu-
cose level.
Encourage the infant to take the
breast or sugar water.
Submit
4. An infant in respiratory distress B. Begin humidified oxygen via hood
is placed on pulse ox. The O2
sat is 85%. What is the priority Rationale
nursing intervention?
An oxygen saturation of less than 90% (normal oxygen
Evaluate the blood pH.
saturation is 96% to 98%) requires oxygen administration
Begin humidified oxygen via
(B). (A) is not necessary. (C) may utilize additional oxygen
hood.
and will not correct the problem. (D) is important because
Stimulate infant crying.
it may decrease energy use for respiratory effort, but it will
Place the infant under a radiant
not correct a low saturation level.
warmer.
5. When assessing a newborn in- C. Count the heart rate for at least one full minute
fant's heart rate, which tech-
, OB/Maternity HESI Assignment
Study online at https://quizlet.com/_e7rago
nique is most important for the Rationale
nurse to use?
Quiet the infant before count- It is most important for the nurse to count the heart rate for
ing the heart rate. at least one full minute (C) so that irregularities or murmurs
Listen at the apex of the heart. can be detected. (A) is not necessary for the heart rate to
Count the heart rate for at least be correctly auscultated. The heart rate can be heard clearly
one full minute. over any point of an infant's chest, not just (B). Immediately
Palpate the umbilical cord. after delivery, (D) will allow the nurse to assess the rate, but
(B) is the most accurate method of obtaining a newborn's
heart rate.
6. The nurse prepares to admin- B. Explore the mother's concerns about the infant receiving
ister an injection of vitamin K an injection of vitamin K.
to a newborn infant. The moth-
er tells the nurse, "Wait! I don't Rationale
want my baby to have a shot."
This mother's concerns should be explored (B) and any
Which response would be best
misconceptions cleared up before the vitamin K is injected.
for the nurse to make?
(A and C) are true but do not communicate the importance
Inform the mother that the in-
of vitamin K administration. Also, parents have the right
jection was prescribed by the
to refuse the injection by signing a refusal form. (D) is
healthcare provider.
providing false reassurance--all injections cause pain.
Explore the mother's concerns
about the infant receiving an in-
jection of vitamin K.
Explain that vitamin K is re-
quired by state law and compli-
ance is mandatory.
Remind the mother that all ba-
bies receive this shot and it is
relatively painless.
Submit
, OB/Maternity HESI Assignment
Study online at https://quizlet.com/_e7rago
7. The nurse is teaching a new A. Avoid alcohol because it is excreted in breast milk
mother about diet and breast-
feeding. Which instruction is Rationale
most important to include in the
Alcohol should be avoided while breastfeeding because,
teaching plan?
when consumed by the mother, it is excreted in breast
Avoid alcohol because it is ex-
milk (A). It also adversely effects the milk ejection reflex.
creted in breast milk.
While (B) may cause some gastric upset in some babies,
Avoid spicy foods to prevent in-
it does not cause colic. (C) should also be included in diet
fant colic.
teaching for a breastfeeding mother, but because it does
Increase caloric intake by ap-
not involve safety to the infant it does not have the same
proximately 500 calories/day.
degree of importance as (A). Recent research has shown
Double prenatal milk intake to
that infants receive very little Vitamin D via the breastmilk
improve Vitamin D transfer to
and some sources recommend Vitamin D supplementation
the infant.
in exclusively breastfed babies to prevent rickets.
8. Which nursing intervention D. Encourage early initiation of breast of formula feeding
best enhances maternal-infant
bonding during the fourth Rationale
stage of labor?
(D) is the best of the interventions listed to encourage
Brighten the lighting so the
maternal-infant bonding. (A, B, and C) are all methods of
mother can view the infant.
promoting maternal-infant bonding but are not usually as
Complete the newborn assess-
effective as initiating infant feeding.
ment as quickly as possible.
Provide positive reinforcement
for maternal care of the infant.
Encourage early initiation of
breast or formula feeding.
Submit
9. A client at 8-weeks gestation D. The heart develops in the third to fifth weeks after con-
asks the nurse about the risk ception.
