RN HESI Maternity | Western Governors University | D
446 | UPDATED Questions with 100% Verified Answers
Q1: A primigravida arrives at the observation unit of the maternity
unit because thinks is in labor. The
nurse applies the external fetal heart monitor and determines
that the fetal heart rate is 140
beats/minute and the contractions are occurring irregularly
every 10 to 15 minutes. What
assessment finding confirms to the nurse that the client is not
labor at this time?
A: Contractions decrease with walking.
Q2: A primipara has delivered a stillborn fetus at 30 weeks
gestation. To asses the parents in the grieving process which
intervention is most for the nurse to implement ?
A. explain the possible cause of the fetal demise
B. Provide a time for the parents to hold their infant in privacy
C. Encourage the parents to seek counseling within the next
few weeks
D. Assist the couple to request autopsy
A: B. provide a time for the parents to hold their infant in privacy
Q3: What is the priority nursing assessment immediately following
the birth of an infant with esophageal atresia and a
tracheoesophageal (the) fistula ?
A: A. body temperature
Q4: A. body temperature
B. level of pain
C. time of first void
D. number of vessels in the cord
A:
Q5: What is the most important assessment for the nurse to
conduct following the administration of epidural anesthesia to
a client who is at 40-weeks gestation?
A. Level of pain sensation
B. Station of presenting part
C. Variability of fetal heart rate
D. Maternal blood pressure
A: D. Maternal blood pressure
,Q6: A 34-week primigravida with pregnancy induced hypertension
(PIH) is receiving Ringer's Lactate 500 ml with magnesium
sulfate 20 grams at the rate of 3 grams/hour. How many
ml/hour should the nurse program the infusion pump? (Enter
numeric value only)
A. 120
B. 70
C. 65
D. 75
A: D. 75
Q7: A mother of a 3-year-old boy has just given birth to a new
baby girl. The little boy asks the nurse, "Why is my baby sister
eating my mommy's breast?" How should the nurse respond?
(Select all that apply)
A. Explain that newborns get milk from their mothers in this
way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
D. Suggest that the baby can also drink from a bottle
E. Clarify that breastfeeding is his mother's choice
A: A. Explain that newborns get milk from their mothers in this way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
Q8: The nurse is examining an infant for possible cryptorchidism.
Which exam technique should be used?
A. Place the infant in side-lying to facilitate the exam
B. Hold the penis and retract the foreskin gently
C. Cleanse the penis with an antiseptic-soaked pad
D. Place the infant in warm room and use a calm approach
A: D. Place the infant in warm room and use a calm approach
Q9: The nurse is planning care for a client at 30-weeks gestation
who is experiencing preterm labor. What maternal
prescription is most important in preventing this fetus from
developing respiratory distress syndrome?
A. Betamethasone (Celestone) 12 mg deep IM
B. Butorphanol 1 mg IV push q2h PRN pain
C. Ampicillin 1 Gram IV push q8h
D. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes
x3
A: A. Betamethasone (Celestone) 12 mg deep IM
,Q10: A 3-month-old with myelomeningocele and atonic bladder is
catheterized every 4 hours to prevent urinary retention. The
home health nurse notes that the child has developed
episodes of sneezing, urticaria, watery eyes, and a rash in the
diaper area. What action is most important for the nurse to
take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change
A: C. Change to latex-free gloves when handling infant
Q11: The nurse is caring for a female client, a primigravida, with
preeclampsia. Findings include +2 proteinuria, BP 172/112
mmHg, facial and hand swelling, complaints of blurry vision
and a severe frontal headache. Which medication should the
nurse anticipate for this client?
A. Clonidine hydrochloride
B. Carbamazepine
C. Furosemide
D. Magnesium sulfate
A: D. Magnesium sulfate
Q12: A client at 35-weeks gestation complains of a "pain whenever
the baby moves." On assessment, the nurse notes the client's
temperature to be 101.2F, with severe abdominal or uterine
tenderness on palpation. The nurse knows that these findings
are indicative of what condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
D. Viral infection.
A: B. Chorioamnionitis
Q13: A male infant with a 2-day history of fever and diarrhea is
brought to a clinic by his mother who tells the nurse that the
child refuses to drink anything. The nurse determines that the
child has a weak cry with no tears. Which prescription is most
important to implement?
A: B. Infuse normal saline intravenously
Q14: A. Provide a bottle of electrolyte solution
B. Infuse normal saline intravenously
C. Administer an antipyretic rectally
D. Apply external cooling blanket
, A:
Q15: A 6-month old child who had a cleft-lip repair has elbow
restraints in place. What nursing intervention should the nurse
plan to implement?
A: D. remove restraints one at a time to provide ROM exercises
Q16: A. remove restraints q4h for 30 minutes and place gloves on
the child's hands
B. record observations of the restraints q2h and ensure that
they are in place at all times
C. obtain the HCP advice as to when the restraints should be
removed
D. remove restraints one at a time to provide ROM exercises
A:
Q17: A new mother calls the nurse stating that she wants to start
feeding her 6-month-old child something besides breast milk,
but is concerned that the infant is too young to start eating
solid foods. How should the nurse respond?
A: D. reassure the mother that the infant is old enough to eat iron-fortified cereal
Q18: A. encourage the mother to schedule a developmental
assessment of the infant
B. advise the mother to wait at least another month before
starting any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit
at each meal
D. reassure the mother that the infant is old enough to eat
iron-fortified cereal
A:
Q19: While caring for a laboring client on continuous fetal
monitoring, the nurse notes a fetal heart rate pattern that falls
and rises abruptly with a "V" shaped appearance. What action
should the nurse take first?
A. Prepare for a potential cesarean
B. Allow the client to begin pushing
C. Administer oxygen at 10/L by mask
D. Change the maternal position
A: D. Change the maternal position
Q20: A postpartum client who is Rh-negative refuses to receive Rho
(D) immune globulin (RhoGam) after delivery of an infant who
446 | UPDATED Questions with 100% Verified Answers
Q1: A primigravida arrives at the observation unit of the maternity
unit because thinks is in labor. The
nurse applies the external fetal heart monitor and determines
that the fetal heart rate is 140
beats/minute and the contractions are occurring irregularly
every 10 to 15 minutes. What
assessment finding confirms to the nurse that the client is not
labor at this time?
A: Contractions decrease with walking.
Q2: A primipara has delivered a stillborn fetus at 30 weeks
gestation. To asses the parents in the grieving process which
intervention is most for the nurse to implement ?
A. explain the possible cause of the fetal demise
B. Provide a time for the parents to hold their infant in privacy
C. Encourage the parents to seek counseling within the next
few weeks
D. Assist the couple to request autopsy
A: B. provide a time for the parents to hold their infant in privacy
Q3: What is the priority nursing assessment immediately following
the birth of an infant with esophageal atresia and a
tracheoesophageal (the) fistula ?
A: A. body temperature
Q4: A. body temperature
B. level of pain
C. time of first void
D. number of vessels in the cord
A:
Q5: What is the most important assessment for the nurse to
conduct following the administration of epidural anesthesia to
a client who is at 40-weeks gestation?
A. Level of pain sensation
B. Station of presenting part
C. Variability of fetal heart rate
D. Maternal blood pressure
A: D. Maternal blood pressure
,Q6: A 34-week primigravida with pregnancy induced hypertension
(PIH) is receiving Ringer's Lactate 500 ml with magnesium
sulfate 20 grams at the rate of 3 grams/hour. How many
ml/hour should the nurse program the infusion pump? (Enter
numeric value only)
A. 120
B. 70
C. 65
D. 75
A: D. 75
Q7: A mother of a 3-year-old boy has just given birth to a new
baby girl. The little boy asks the nurse, "Why is my baby sister
eating my mommy's breast?" How should the nurse respond?
(Select all that apply)
A. Explain that newborns get milk from their mothers in this
way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
D. Suggest that the baby can also drink from a bottle
E. Clarify that breastfeeding is his mother's choice
A: A. Explain that newborns get milk from their mothers in this way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
Q8: The nurse is examining an infant for possible cryptorchidism.
Which exam technique should be used?
A. Place the infant in side-lying to facilitate the exam
B. Hold the penis and retract the foreskin gently
C. Cleanse the penis with an antiseptic-soaked pad
D. Place the infant in warm room and use a calm approach
A: D. Place the infant in warm room and use a calm approach
Q9: The nurse is planning care for a client at 30-weeks gestation
who is experiencing preterm labor. What maternal
prescription is most important in preventing this fetus from
developing respiratory distress syndrome?
A. Betamethasone (Celestone) 12 mg deep IM
B. Butorphanol 1 mg IV push q2h PRN pain
C. Ampicillin 1 Gram IV push q8h
D. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes
x3
A: A. Betamethasone (Celestone) 12 mg deep IM
,Q10: A 3-month-old with myelomeningocele and atonic bladder is
catheterized every 4 hours to prevent urinary retention. The
home health nurse notes that the child has developed
episodes of sneezing, urticaria, watery eyes, and a rash in the
diaper area. What action is most important for the nurse to
take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change
A: C. Change to latex-free gloves when handling infant
Q11: The nurse is caring for a female client, a primigravida, with
preeclampsia. Findings include +2 proteinuria, BP 172/112
mmHg, facial and hand swelling, complaints of blurry vision
and a severe frontal headache. Which medication should the
nurse anticipate for this client?
A. Clonidine hydrochloride
B. Carbamazepine
C. Furosemide
D. Magnesium sulfate
A: D. Magnesium sulfate
Q12: A client at 35-weeks gestation complains of a "pain whenever
the baby moves." On assessment, the nurse notes the client's
temperature to be 101.2F, with severe abdominal or uterine
tenderness on palpation. The nurse knows that these findings
are indicative of what condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
D. Viral infection.
A: B. Chorioamnionitis
Q13: A male infant with a 2-day history of fever and diarrhea is
brought to a clinic by his mother who tells the nurse that the
child refuses to drink anything. The nurse determines that the
child has a weak cry with no tears. Which prescription is most
important to implement?
A: B. Infuse normal saline intravenously
Q14: A. Provide a bottle of electrolyte solution
B. Infuse normal saline intravenously
C. Administer an antipyretic rectally
D. Apply external cooling blanket
, A:
Q15: A 6-month old child who had a cleft-lip repair has elbow
restraints in place. What nursing intervention should the nurse
plan to implement?
A: D. remove restraints one at a time to provide ROM exercises
Q16: A. remove restraints q4h for 30 minutes and place gloves on
the child's hands
B. record observations of the restraints q2h and ensure that
they are in place at all times
C. obtain the HCP advice as to when the restraints should be
removed
D. remove restraints one at a time to provide ROM exercises
A:
Q17: A new mother calls the nurse stating that she wants to start
feeding her 6-month-old child something besides breast milk,
but is concerned that the infant is too young to start eating
solid foods. How should the nurse respond?
A: D. reassure the mother that the infant is old enough to eat iron-fortified cereal
Q18: A. encourage the mother to schedule a developmental
assessment of the infant
B. advise the mother to wait at least another month before
starting any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit
at each meal
D. reassure the mother that the infant is old enough to eat
iron-fortified cereal
A:
Q19: While caring for a laboring client on continuous fetal
monitoring, the nurse notes a fetal heart rate pattern that falls
and rises abruptly with a "V" shaped appearance. What action
should the nurse take first?
A. Prepare for a potential cesarean
B. Allow the client to begin pushing
C. Administer oxygen at 10/L by mask
D. Change the maternal position
A: D. Change the maternal position
Q20: A postpartum client who is Rh-negative refuses to receive Rho
(D) immune globulin (RhoGam) after delivery of an infant who
