HESI A2 Exit Exam Maternity Practice (Question &Answer A+ Graded 100% Verified)

HESI A2 Exit Exam Maternity Practice (Question &Answer A+ Graded 100% Verified) At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next? a. Check the hematocrit results. b. Administer pain medication. c. Increase the rate of IV fluids. d. Monitor client for contractions. Correct Answer:c. increase the rate of IV fluids A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask wen she could use a home pregnancy test to diagnose pregnancy. Which response is best? a. a home pregnancy test can be used right after your first missed period b. these tests are most accurate after you have missed your second period c. home pregnancy tests often give false positives and should not be trusted d. the test can provide accurate information when used right after ovulation Correct Answer:a. a home pregnancy test can be used right after your first missed period 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. shortness of breath b. joint pain c. a persistent cold d. organmegaly Correct Answer:c. a persistent cold Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take? a. notify the healthcare provider or anesthesiologist b. continue to assess the blood pressure q5min c. place the woman in a lateral position d. turn off continuous epidural Correct Answer:c. place the woman in a lateral position In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the week c. anterior fontanel closes at 8 to 11 months and the posterior by the end of the second week d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month Correct Answer:d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? a. patellar reflex 4+ b. blood pressure 158/80 c. four hour urine output 240 ml d. respiration 12/minute Correct Answer:a. patellar reflex 4+ A 4 week old premature infant has been receiving epoetin alfa for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? a. slowly increasing urine output over the last week b. respiratory rate changes from the 40s to the 60s c. changes in apical heart rate from the 180 to the 140s d. change in indirect bilirubin from 12 mg/dl to 8 mg/dl Correct Answer:c. changes in apical rate from the 180s to the 140s A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nagele's rule, what is the estimated date of delivery? a. April 25, 2007 b. May 9, 2007 c. May 29, 2007 d. June 2, 2007 Correct Answer:b. May 9, 2007 The nurse is performing a AGA on a full-term newborn during the first hour of transition using the Dubowitz scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. Which findings should the nurse identify to determine if the neonate is SGA? (Select all that apply.) a. admission weight of 4 lbs 15 oz b. head to heel length of 17 in c. frontal occipital circumference of 12.5 in d. skin smooth with visible veins and abundant vernix e. anterior plantar crease and smooth heel surfaces f. full flexion of all extremities in resting supine position Correct Answer:a, b, c The nurse assess a client admitted to the labor and delivery unit and obtains the following data: BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? a. insert a fetal monitor b. assess for cervical changes q1H c. monitor bleeding from IV sites d. perform Leopold's maneuvers Correct Answer:c. monitor for bleeding from IV sites Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assess an apical heart rate of 80 bpm and respirations 20. What action should the nurse perform next? a. initiate positive pressure ventilation b. intervene after one minute APGAR is assessed c. initiate CPR on the infant d. assess the infant's blood glucose level Correct Answer:a. initiate positive pressure ventilation 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 cm dilated and 75% effaced. What additional information is most important for the nurse to obtain? a. gravidity and parity b. time and amount of last oral intake c. date of last normal menstrual period d. frequency and intensity of contractions Correct Answer:c. date of last normal menstrual period A mutigravida client at 41 weeks gestation present 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? a. biophysical profile b. ultrasound for fetal abnormalities c. maternal serum alpha-fetoprotein screening d. percutaneous umbilical blood sampling Correct Answer:a. biophysical profile A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? a. raise the foot of the bed b. assess for vaginal bleeding c. evaluate the fetal heart rate d. take the client's blood pressure Correct Answer:a. raise the foot of the bed 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? a. come to the clinic today for an ultrasound b. go immediately to the emergency room c. lie on your left side for about one hour and see if the bleeding stops d. bring a urine specimen to the lab tomorrow to determine if you have a UTI Correct Answer:a. come to the clinic today for an ultrasound Which nursing intervention is helpful in relieving "afterpains"? a. using relaxation breathing techniques b. using a breast pump c. massaging the abdomen d. giving oxytocic medications Correct Answer:a. using relaxation breathing techniques The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurses should know that ovulation usually occurs a. two weeks before menstruation b. immediately after menstruation c. immediately before menstruation d. three weeks before menstruation Correct Answer:a. two weeks before menstruation A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurses's response should be based on what information? a. males inherit the disorder with a greater frequency than females b. each pregnancy carries a 50% chance of inheriting the disorder c. the disorder occurs in 25% of pregnancies d. all children will be carriers of the disorder Correct Answer:b. each pregnancy carries 50% chance of inheriting the disorder The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? a. yellowish tinge to the skin b. Babinski reflex present bilaterally c. pink papular rash on the face d. Moro reflex noted after a loud noise Correct Answer:a. yellowish tinge to the skin A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? a. elevate lower legs while resting b. increase caloric intake by 200 to 300 calories per day c. increase water intake to 8 full glasses per day d. take prescribed multivitamin and mineral supplements Correct Answer:d. take prescribed multivitamin and mineral supplements Which assessment finding should the nursery