Maternity HESI Test bank (combined red hesi and other sources) Questions With Rationales All Verified (A+)

Maternity HESI Test bank (combined red hesi and other sources) Questions With Rationales All Verified (A+) An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father? A.Suggest that his wife seek professional counseling to deal with her symptoms. B.Explain that his wife is exhibiting ambivalence about the pregnancy. C. Ask him to report similar abnormal behaviors at the next prenatal visit. D.Reassure him that normal maternal-fetal bonding is occurring. - Correct ANS-D) Reassure him that normal maternal-fetal bonding is occurring. Rationale: These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester. Options A and C are not necessary because the behaviors displayed are normal. The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A.Maternal blood pressure B.Maternal temperature C.Fetal heart rate (FHR) D.White blood cell count (WBC) - Correct ANS-C. Fetal heart rate (FHR) Rationale: The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency. Option A should be assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is monitored hourly after the membranes are ruptured to detect the development of amnionitis. Option D should be determined for all clients in labor. A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A.Cyanosis of the hands and feet B.Skin color that is slightly jaundiced C.Tiny white papules on the nose or chin D.Red patches on the cheeks and trunk - Correct ANS-B. Skin color that is slightly jaundiced Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia are small white papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in newborns. A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A.Breastfeed the infant, ensuring that both breasts are completely emptied. B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C.Breastfeed on the unaffected breast only until the mastitis subsides. D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. - Correct ANS-A.Breastfeed the infant, ensuring that both breasts are completely emptied. Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease antibiotic effects on the infant. A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities? The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? a. Insert an internal fetal monitor b. Assess for cervical changes q1h c. Monitor bleeding from IV sites d. Perform Leopold's maneuvers - Correct ANS-c. Monitor bleeding from IV sites Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruption, characterized by abnormal bleeding. A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? a. Supplementary iron is more efficiently utilized during pregnancy b. It it difficult to consume 18 mg of additional iron by diet alone c. Iron absorption is decreased in the GI tract during pregnancy d. Iron is needed to prevent megaloblastic anemia in the last trimester - Correct ANS-b. It is difficult to consume 18 mg of additional iron by diet alone Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult (B) so iron supplements are often recommended. A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? a. Transition labor with contractions every 2 minutes, lasting 90 seconds each a. Early labor with contractions every 5 minutes, lasting 40 seconds each c. Active labor with contractions every 31 minutes, lasting 60 seconds each d. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each - Correct ANS-a. Transition labor with contractions every 2 minutes, lasting 90 seconds each Contractions pattern (A) describes hyperstimulation and an inadequate resting time between contractions to allow for placental perfusion. The oxytocin infusion should be discontinued. Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? 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) A. Litmus paper B. fetal scalp electrode C. a sterile glove D. an amniotic hook E. sterile vaginal speculum F. a Doppler - Correct ANS-C. a sterile glove D. an amniotic hook F. a Doppler A 30 year old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg SQ. Which assessment is the highest priority for the nurse to monitor during the adminstration of this drug? A. maternal blood pressure and respirations B. maternal and fetal heart rates C. hourly urinary output D. deep tendon reflexes - Correct ANS-B. maternal and fetal heart rates A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A. 3+ deep tendon reflexes and hyperclonus B. periorbital edema, flashing lights, and aura C. epigastric pain in the third trimester D. recent decreased urinary output - Correct ANS-A. 3+ deep tendon reflexes and hyperclonus Put the following actions in order to prevent hypotension in the pregnant client: 1. reposition the client 2. provide oxygen via face mask 3. increase IV fluid 4. call the healthcare provider - Correct ANS-1. reposition the client 2. increase the IV fluid 3. provide oxygen via face mask 4. call the healthcare provider