Maternity HESI Questions (2) With Correct Answers

The nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. soft abdomen 2. uterine tenderness 3. absence of abdominal pain 4. painless, bright red vaginal bleeding - Answer 2. uterine tenderness The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the HCP's prescriptions and should questions which one? 1. prepare client for an US 2. obtain equipment for a manual pelvic exam re to draw a Hgb and Hct blood sample 4. obtain equipment for external electronic FHR monitoring - Answer 2. manual pelvic examination An ultra sound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the US indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. delivery of the fetus 2. strict I&O monitoring 3. complete bedrest for the rest of the pregnancy 4. weekly monitoring of coagulation studies until delivery - Answer 1. delivery of fetus The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35 y.o primigravida 2. the client has a hx of cardiac disease 3. the client's hbg is 13.5 4. the client is a 20 y.o. primigravida of average wt and ht - Answer 2. hx of cardiac disease The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. hypotonic 2. precipitous 3. hypertonic 4. preterm - Answer 1. hypotonic After a precipitous deliver, the nurse notes that the new mother is passive and only touches her newborn infant briefly wiht her fingertips. What should the nurse do to help the woman process the delivery? 1. encourage her to breastfeed soon after the birth 2. support her reaction to the newborn infant 3. tell the mother that it is important to hold her infant 4. document a complete account of the mother's reaction on the birth record - Answer 2. support her reaction to the newborn infant The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. maternal fatigue 2. coordinated uterine contractions 3. progressive changes in cervix 4. persistent nonreassuring FHR - Answer 4. persistent nonreassuring FHR The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. provide pain relief measures 2. prepare client for an amniotomy 3. promote ambulation q30min 4. monitor oxytocin infusion closely - Answer 1. provide pain relief The nurse is reviewing the HCP's prescriptions for a client admitted for PROM. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. monitor FHR continuously 2. monitor maternal VS closely 3. perform a vaginal exam every shift 4. administer ampicillin 1g as an IV piggyback q6hrs - Answer 3. perform a vaginal exam every shift The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. provide comfort measures 2. monitor FHR 3. change client's position frequently 4. keep significant other informed of progress of labor - Answer 2. monitor FHR