HESI RN Maternity Assignment Questions and Correct Answers

HESI RN Maternity Assignment Questions and Correct Answers At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention? -uterine cramping -abdominal tenderness -systolic bp <100 mmHg -intermittent nausea A. Uterine cramping A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client? -the client may have a bladder or kidney infection -bladder capacity increases during pregnancy -during pregnancy a woman is especially sensitive to body functions -the growing uterus is putting pressure on the bladder D. The growing uterus is putting pressure on the bladder. The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute, and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? -check the infant's ABGs -notify the pediatrician of the infants VS -assess the infant's blood glucose level -encourage the infant to take the breast or sugar water C. Assess the infant's blood glucose level An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing intervention? -evaluate the blood pH -begin humidified oxygen via hood -stimulate infant crying -place the infant under a radiant warmer B. Begin humidified oxygen via hood When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? -quiet the infant before counting the HR -listen at the apex of the heart -count the HR for at least one full minute -palpate the umbilical cord C. Count the heart rate for at least one full minute The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make? -inform the mother that the injection was prescribed by the HCP -explore the mother's concerns about the infant receiving an injection of vitamin K -explain that vitamin K is required by state law and compliance is mandatory -remind the mother that all babies receive this shot and it is relatively painless B. Explore the mother's concerns about the infant receiving an injection of vitamin K The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? -avoid alcohol bc it is excreted in breast milk -avoid spicy foods to prevent infant colic -increase caloric intake by approx. 500 calories/day -double prenatal milk intake to improve vitamin D transfer to the infant A. Avoid alcohol because it is excreted in breast milk Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor? -brighten the lighting so the mother can view the infant -complete the newborn assessment as quickly as possible -provide positive reinforcement for maternal care of infant -encourage early initiation of breast or formula feeding D. Encourage early initiation of breast of formula feeding A client at 8-weeks gestation asks the nurse about the risk fora congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur? -it depends on what the causative factors are for a CHD -we don't really know what or when CHDs occur -they usually occur in the first trimester of pregnancy -the heart develops in the third to fifth weeks after conception D. The heart develops in the third to fifth weeks after conception A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide? -many women imagine what their baby is like by interpreting fetal movements -the fetus in utero is capable of hearing and does respond to the mothers voice -the HCP should address her concerns about her baby hearing function -the interaction b/w the mothers voice and the fetus's response ensures bonding B. The fetus in utero is capable of hearing and does respond to the mother's voice A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide? -this is a demonstration of the fetus acoustical reflux -the fetus can respond to sound by 24 weeks -it is a coincidence the fetus responded at the same time -report behavior to HCP B. The fetus can respond to sound by 24-weeks gestation