NU472 HESI Obstetrics/Maternity Practice
Exam - 103 Questions
The nurse identifies crepitus when examining the chest of a newborn who was delivered
vaginally. Which further assessment should the nurse perform?
o Elicit a positive scarf sign on the affected side.
o Observe for an asymmetrical Moro (startle) reflex.
o Watch for swelling of fingers on the affected side.
o Note paralysis of affected extremity and muscles.
o Observe for an asymmetrical Moro (startle) reflex.
· The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle.
Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant
has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus
over the clavicle, focal swelling or tenderness, or cries when the arm is moved.
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?
o Yellowish tinge to the skin.
o Babinski reflex present bilaterally.
o Pink papular rash on the face.
o Moro reflex noted after a loud noise.
o Yellowish tinge to the skin.
· Cephalohematomas are characterized by bleeding between the bone and its covering, the
periosteum. Due to the breakdown of the red blood cells within a hematoma, the infant is at a
greater risk for jaundice thus it should be reported.
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A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data would indicate to the nurse that the client is
experiencing magnesium sulfate toxicity?
o Deep tendon reflexes 2+.
o Blood pressure 140/90.
o Respiratory rate 18/minute.
o Urine output 90 ml/4 hours.
o Urine output 90 ml/4 hours.
A client experiencing urine outputs of less than 100 ml/4 hours, absent DTRs, and a respiratory
rate of less than 12 breaths/minute is exhibiting symptoms of magnesium sulfate toxicity and
requires immediate attention.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which
adverse effect should the nurse monitor for during the infusion of Pitocin?
o Dehydration.
o Hyperstimulation.
o Galactorrhea.
,o Fetal tachycardia.
o Hyperstimulation.
· Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the
client is at risk for hyperstimulation which can lead to tetanic contractions, uterine rupture, and
fetal distress or demise.
We have an expert-written solution to this problem!
The nurse is preparing to give an enema to a laboring client. Which client would require the
most caution when carrying out this procedure?
o A gravida 6, para 5 who is 38 years of age and in early labor.
o A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1
station.
o A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of
labor due to post dates.
o A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not
engaged.
o A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not
engaged.
· When the presenting part is ballottable, it is floating out of the pelvis. In such a situation, the
cord can descend before the fetus causing a prolapsed cord, which is an emergency situation.
What action should the nurse implement to decrease the client's risk for hemorrhage after a
cesarean section?
o Monitor urinary output via an indwelling catheter.
o Assess the abdominal dressings for drainage.
o Give the Ringer's Lactated infusion at 125 ml/hr.
o Check the firmness of the uterus every 15 minutes.
, o Check the firmness of the uterus every 15 minutes.
· A client's risk of postpartal hemorrhage is decreased when the uterus is firm after delivery of
the infant. Assessment of fundus consistency q15 minutes provides frequent intervals to
stimulate the fundus to contract and prevent bleeding.
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this
client?
o "Which symptom did you experience first?"
o "Are you eating large amounts of salty foods?"
o "Have you visited a foreign country recently?"
o "Do you have a history of rheumatic fever?"
o "Do you have a history of rheumatic fever?"
· Obtaining a client's health history is a priority because clients with a history of rheumatic fever
may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to
the increased blood volume that occurs during pregnancy.
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 nurse's response should be based
on what information?
o Males inherit the disorder with a greater frequency than females.
o Each pregnancy carries a 50% chance of inheriting the disorder.
o The disorders can occur in 25% of pregnancies.
o All children will be carriers of the disorder.
o Each pregnancy carries a 50% chance of inheriting the disorder.
· According to the laws of inheritance, an autosomal dominant disorder has a 50% chance of
being transmitted with each pregnancy, and if transmitted, the disorder will appear in the child.
Exam - 103 Questions
The nurse identifies crepitus when examining the chest of a newborn who was delivered
vaginally. Which further assessment should the nurse perform?
o Elicit a positive scarf sign on the affected side.
o Observe for an asymmetrical Moro (startle) reflex.
o Watch for swelling of fingers on the affected side.
o Note paralysis of affected extremity and muscles.
o Observe for an asymmetrical Moro (startle) reflex.
· The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle.
Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant
has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus
over the clavicle, focal swelling or tenderness, or cries when the arm is moved.
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?
o Yellowish tinge to the skin.
o Babinski reflex present bilaterally.
o Pink papular rash on the face.
o Moro reflex noted after a loud noise.
o Yellowish tinge to the skin.
· Cephalohematomas are characterized by bleeding between the bone and its covering, the
periosteum. Due to the breakdown of the red blood cells within a hematoma, the infant is at a
greater risk for jaundice thus it should be reported.
,Brainpower
Read More
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:15
Full screen
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data would indicate to the nurse that the client is
experiencing magnesium sulfate toxicity?
o Deep tendon reflexes 2+.
o Blood pressure 140/90.
o Respiratory rate 18/minute.
o Urine output 90 ml/4 hours.
o Urine output 90 ml/4 hours.
A client experiencing urine outputs of less than 100 ml/4 hours, absent DTRs, and a respiratory
rate of less than 12 breaths/minute is exhibiting symptoms of magnesium sulfate toxicity and
requires immediate attention.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which
adverse effect should the nurse monitor for during the infusion of Pitocin?
o Dehydration.
o Hyperstimulation.
o Galactorrhea.
,o Fetal tachycardia.
o Hyperstimulation.
· Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the
client is at risk for hyperstimulation which can lead to tetanic contractions, uterine rupture, and
fetal distress or demise.
We have an expert-written solution to this problem!
The nurse is preparing to give an enema to a laboring client. Which client would require the
most caution when carrying out this procedure?
o A gravida 6, para 5 who is 38 years of age and in early labor.
o A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1
station.
o A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of
labor due to post dates.
o A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not
engaged.
o A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not
engaged.
· When the presenting part is ballottable, it is floating out of the pelvis. In such a situation, the
cord can descend before the fetus causing a prolapsed cord, which is an emergency situation.
What action should the nurse implement to decrease the client's risk for hemorrhage after a
cesarean section?
o Monitor urinary output via an indwelling catheter.
o Assess the abdominal dressings for drainage.
o Give the Ringer's Lactated infusion at 125 ml/hr.
o Check the firmness of the uterus every 15 minutes.
, o Check the firmness of the uterus every 15 minutes.
· A client's risk of postpartal hemorrhage is decreased when the uterus is firm after delivery of
the infant. Assessment of fundus consistency q15 minutes provides frequent intervals to
stimulate the fundus to contract and prevent bleeding.
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this
client?
o "Which symptom did you experience first?"
o "Are you eating large amounts of salty foods?"
o "Have you visited a foreign country recently?"
o "Do you have a history of rheumatic fever?"
o "Do you have a history of rheumatic fever?"
· Obtaining a client's health history is a priority because clients with a history of rheumatic fever
may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to
the increased blood volume that occurs during pregnancy.
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 nurse's response should be based
on what information?
o Males inherit the disorder with a greater frequency than females.
o Each pregnancy carries a 50% chance of inheriting the disorder.
o The disorders can occur in 25% of pregnancies.
o All children will be carriers of the disorder.
o Each pregnancy carries a 50% chance of inheriting the disorder.
· According to the laws of inheritance, an autosomal dominant disorder has a 50% chance of
being transmitted with each pregnancy, and if transmitted, the disorder will appear in the child.
