NURS 405 HESI QUESTIONS SAUNDERS
WITH CORRECT ANSWERS
Whenxreturningxforxthexresultsxofxherxmaternalxserumxalpha-
fetoproteinx(MSAFP),xaxprimigravidaxasksxthexnursexhowxproblemsxwithxherxbabyxcanxbex
detectedxbyxthextest.xWhatxinformationxwillxthexnursexgivextoxthexclientxtoxbestxdescribexho
wxthextestxisxinterpreted?x-xans--
A:xIfxMSAFPxandxestriolxlevelsxarexlowxandxthexhCGxlevelxisxhigh,xresultsxarexpositivexforxa
xpossiblexchromosomalxdefect.
Rationale:x
LowxlevelsxofxMSAFPxandxestriolxandxelevatedxlevelsxofxhCGxfoundxinxthexmaternalxbloodx
samplexarexindicationsxofxpossiblexchromosomalxdefects.xHighxlevelsxofxMSAFPxandxestri
olxinxthexbloodxsamplexafterx15xweeksxofxgestationxcanxindicatexaxneuralxtubexdefect,xsuch
xasxspinaxbifidaxandxanencephaly,xnotxchromosomalxdefects.xOnexofxthexlimitationsxofxthex
multiplexmarkerxscreeningxisxthatxanyxdefectsxcoveredxbyxskinxwillxnotxbexevidentxinxthexbl
oodxsampling.xAfterx15xweeksxofxgestation,xtherexwillxbextracesxofxMSAFP,xestriol,xandxhC
Gxinxthexbloodxsample.
Thexnursexisxpreparingxaxlaboringxclientxforxanxamniotomy.xImmediatelyxafterxthexprocedu
rexisxcompleted,xitxisxmostximportantxforxthexnursextoxobtainxwhichxinformation?
A.xMaternalxbloodxpressure
B.xMaternalxtemperature
C.xFetalxheartxratex(FHR)
D.Whitexbloodxcellxcountx(WBC)x-xans--C.xFetalxheartxratex
Rationale:ThexFHRxshouldxbexassessedxbeforexandxafterxthexprocedurextoxdetectxchange
sxthatxmayxindicatexthexpresencexofxcordxcompressionxorxprolapse.xAnxamniotomyx(artifici
alxrupturexofxmembranesx[AROM])xisxusedxtoxstimulatexlaborxwhenxthexconditionxofxthexce
rvixxisxfavorable.xThexfluidxshouldxbexassessedxforxcolor,xodor,xandxconsistency.xOptionxAx
shouldxbexassessedxeveryx15-
20xminutesxduringxlaborxbutxisxnotxspecificxforxAROM.xOptionxBxisxmonitoredxhourlyxafterxt
hexmembranesxarexrupturedxtoxdetectxthexdevelopmentxofxamnionitis.xOptionxDxshouldxbe
xdeterminedxforxallxclientsxinxlabor.
,Sixxhoursxafterxanxoxytocinxinductionxwasxbegunxandx2xhoursxafterxspontaneousxrupturexo
fxthexmembranes,xthexnursexnotesxseveralxsuddenxdecreasesxinxthexfetalxheartxratexwithxq
uickxreturnxtoxbaseline,xwithxandxwithoutxcontractions.xBasedxonxthisxfetalxheartxratexpatter
n,xwhichxinterventionxisxbestxforxthexnursextoximplement?x-xans--
A:xPlacexthexclientxinxaxslightxTrendelenburgxposition.
Rationale:
ThexgoalxisxtoxrelievexpressurexonxthexumbilicalxcordxandxplacingxthexclientxinxaxslightxTren
delenburgxpositionxisxmostxlikelyxtoxrelievexthatxpressure.xThexFHRxpatternxisxindicativexofx
axvariablexfetalxheartxratexdeceleration,xwhichxisxtypicallyxcausedxbyxcordxcompressionxan
dxcanxoccurxwithxorxwithoutxcontractions.xOptionxAxmayxbexhelpfulxtoxincreasexvascularxsp
acexbutxisxnotxasxlikelyxtoxrelievexthexpressurexasxthexTrendelenburgxposition.xOptionxBxisx
notxhelpfulxwithxcordxcompression.xOptionxDxisxnotxthexpriorityxinterventionxatxthisxtime.xAft
erxrepositioningxthexclient,xaxvaginalxexaminationxisxindicatedxtoxrulexoutxcordxprolapsexan
dxassessxforxcervicalxchange.
Axbreastfeedingxpostpartumxclientxisxdiagnosedxwithxmastitis,xandxantibioticxtherapyxisxpre
scribed.xWhichxinstructionxshouldxthexnursexprovidextoxthisxclient?x-xans--
A:xBreastfeedxthexinfant,xensuringxthatxbothxbreastsxarexcompletelyxemptied.
Rationale:
Mastitis,xcausedxbyxpluggedxmilkxducts,xisxrelatedxtoxbreastxengorgement,xandxbreastfeed
ingxduringxmastitisxfacilitatesxthexcompletexemptyingxofxengorgedxbreasts,xeliminatingxthex
pressurexonxthexinflamedxbreastxtissue.xOptionxBxisxlessxpainfulxbutxdoesxnotxfacilitatexco
mpletexemptyingxofxthexbreastxtissue.xOptionxCxwillxnotxrelievexthexengorgementxonxthexaff
ectedxside.xOptionxDxwillxnotxdecreasexantibioticxeffectsxonxthexinfant.
Axnewbornxinfant,xdiagnosedxwithxdevelopmentalxdysplasiaxofxthexhipx(DDH),xisxbeingxpre
paredxforxdischarge.xWhichxnursingxactionxshouldxbexincludedxinxthisxinfant'sxdischargexte
achingxplan?x-xans--A:xObservexthexparentsxapplyingxaxPavlikxharness.x
Rationale:xItxisximportantxthatxthexhipsxofxinfantsxwithxhipxdysplasiaxarexmaintainedxinxanxa
bductedxposition,xwhichxcanxbexaccomplishedxbyxusingxthexPavlikxharness;xthisxkeepsxthe
xhipsxandxkneesxflexed,xthexhipsxabducted,xandxthexfemoralxheadxinxthexacetabulum.xEarly
xtreatmentxoftenxnegatesxthexneedxforxsurgery,xandxoptionxBxisxnotxindicatedxuntilxapproxi
matelyx6xmonthsxofxage.xOptionxCxisxnotxindicatedxforxhipxdysplasia.xItxisxbestxforxthexpedia
tricianxtoxmonitorxhipxjointxmobility,xandxteachingxthexparentsxtoxperformxthisxtechniquexisxli
kelyxtoxincreasextheirxanxiety.
Whenxpreparingxaxclassxonxnewbornxcarexforxexpectantxparents,xwhichxisxcorrectxforxthexn
ursextoxteachxconcerningxthexnewbornxinfantxbornxatxtermxgestation?x-xans--
A:xVernixxisxaxwhitexcheesyxsubstance,xpredominantlyxlocatedxinxthexskinxfolds
Rationale:x
Vernix,xfoundxinxthexfoldsxofxthexskin,xisxaxcharacteristicxofxtermxinfants.xMiliaxarexnotxredx
marksxmadexbyxforcepsxbutxarexwhitexpinpointxspotsxusuallyxfoundxoverxthexnosexandxchin
, xthatxrepresentxblockagexofxthexsebaceousxglands.xMeconiumxisxthexfirstxstool,xbutxitxisxtar
ryxblack,xnotxyellow.xPseudostrabismusx(crossedxeyes)xisxnormalxatxbirthxthroughxthexthird
xorxfourthxmonthxandxdoesxnotxrequirexsurgery.
Clientxteachingxisxanximportantxpartxofxthexperinatalxnurse'sxrole.xWhichxfactorxhasxthexgre
atestxinfluencexonxsuccessfulxteachingxofxthexpregnantxclient?x-xans--
A:xThexclient'sxinvestmentxinxwhatxisxbeingxtaught
Rationale:Whenxteachingxanyxclient,xreadinessxtoxlearnxisxrelatedxtoxhowxmuchxthexclientx
hasxinvestedxinxwhatxisxbeingxtaughtxorxhowximportantxthexmaterialsxarextoxthexclient'sxpart
icularxlife.xForxexample,xthexclientxwithxseverexmorningxsicknessxinxthexfirstxtrimesterxmayx
notxbexreadyxtoxlearnxaboutxlaborxandxdeliveryxbutxisxprobablyxveryxreadyxtoxlearnxaboutxw
aysxtoxrelievexmorningxsickness.xOptionsxBxandxCxarexfactorsxthatxmayxinfluencexlearningx
butxarexnotxasxinfluentialxasxoptionxA.xEvenxifxaxpregnancyxisxplannedxandxveryxdesirable,xt
hexclientxmustxbexreadyxtoxlearnxthexcontentxpresented.
Whenxaxnewxmotherxreceivesxherxinfantxforxthexfirstxtime,xwhichxbehaviorxisxmostxreassuri
ngxtoxthexnurse?x-xans--
A:xHerxarmsxandxhandsxreceivexthexinfant,xandxshexthenxtracesxthexinfant'sxprofilexwithxher
xfingertips.
Rationale:x
Attachmentxandxbondingxtheoryxindicatexthatxmostxmothersxwillxdemonstratexbehaviorsxd
escribedxinxoptionxBxduringxthexfirstxvisitxwithxthexnewborn,xwhichxmayxbexatxdeliveryxorxlat
er.xAfterxthexfirstxvisit,xthexmotherxmayxexhibitxdifferentxtouchingxbehaviorsxsuchxasxeagerl
yxreachingxforxthexinfantxandxcuddlingxthexinfantxclosextoxher.
Whenxassessingxaxclientxatx12xweeksxofxgestation,xthexnursexrecommendsxthatxshexandxh
erxhusbandxconsiderxattendingxchildbirthxpreparationxclasses.xWhenxisxthexbestxtimexforxt
hexcouplextoxattendxthesexclasses?x-xans--A:xAtx30xweeksxofxgestation
Rationale:x
Learningxisxfacilitatedxbyxinterestedxcouple.xThexcouplexisxmostxinterestedxinxchildbirthxto
wardxthexendxofxthexpregnancy,xwhenxtheyxarexbeginningxtoxanticipatexthexonsetxofxlaborx
andxthexbirthxofxtheirxchild.xOptionxDxisxclosestxtoxthextimexwhenxparentsxwouldxbexreadyxf
orxsuchxclasses.xOptionsxA,xB,xandxCxarexnotxthexbestxtimesxduringxaxpregnancyxforxthexco
uplextoxattendxchildbirthxeducationxclasses.xAtxthesextimesxtheyxwillxhavexotherxteachingxn
eeds.xEarlyxpregnancyxclassesxoftenxincludextopicsxsuchxasxnutrition,xphysiologicxchange
s,xcopingxwithxnormalxdiscomfortsxofxpregnancy,xfetalxdevelopment,xmaternalxandxfetalxris
kxfactors,xandxevolvingxrolesxofxthexmotherxandxherxsignificantxothers
Anxexpectantxfatherxtellsxthexnursexhexisxconcernedxaboutxsomexofxhisxwife'sxbehaviors.xH
exstatesxthatxshexisxconstantlyxrubbingxherxabdomenxandxtalkingxtoxthexbaby.xWhichxreco
mmendationxshouldxthexnursexmakextoxthisxexpectantxfather?x-xans--
A:xReassurexhimxthatxnormalxmaternal-fetalxbondingxisxoccurring.x
WITH CORRECT ANSWERS
Whenxreturningxforxthexresultsxofxherxmaternalxserumxalpha-
fetoproteinx(MSAFP),xaxprimigravidaxasksxthexnursexhowxproblemsxwithxherxbabyxcanxbex
detectedxbyxthextest.xWhatxinformationxwillxthexnursexgivextoxthexclientxtoxbestxdescribexho
wxthextestxisxinterpreted?x-xans--
A:xIfxMSAFPxandxestriolxlevelsxarexlowxandxthexhCGxlevelxisxhigh,xresultsxarexpositivexforxa
xpossiblexchromosomalxdefect.
Rationale:x
LowxlevelsxofxMSAFPxandxestriolxandxelevatedxlevelsxofxhCGxfoundxinxthexmaternalxbloodx
samplexarexindicationsxofxpossiblexchromosomalxdefects.xHighxlevelsxofxMSAFPxandxestri
olxinxthexbloodxsamplexafterx15xweeksxofxgestationxcanxindicatexaxneuralxtubexdefect,xsuch
xasxspinaxbifidaxandxanencephaly,xnotxchromosomalxdefects.xOnexofxthexlimitationsxofxthex
multiplexmarkerxscreeningxisxthatxanyxdefectsxcoveredxbyxskinxwillxnotxbexevidentxinxthexbl
oodxsampling.xAfterx15xweeksxofxgestation,xtherexwillxbextracesxofxMSAFP,xestriol,xandxhC
Gxinxthexbloodxsample.
Thexnursexisxpreparingxaxlaboringxclientxforxanxamniotomy.xImmediatelyxafterxthexprocedu
rexisxcompleted,xitxisxmostximportantxforxthexnursextoxobtainxwhichxinformation?
A.xMaternalxbloodxpressure
B.xMaternalxtemperature
C.xFetalxheartxratex(FHR)
D.Whitexbloodxcellxcountx(WBC)x-xans--C.xFetalxheartxratex
Rationale:ThexFHRxshouldxbexassessedxbeforexandxafterxthexprocedurextoxdetectxchange
sxthatxmayxindicatexthexpresencexofxcordxcompressionxorxprolapse.xAnxamniotomyx(artifici
alxrupturexofxmembranesx[AROM])xisxusedxtoxstimulatexlaborxwhenxthexconditionxofxthexce
rvixxisxfavorable.xThexfluidxshouldxbexassessedxforxcolor,xodor,xandxconsistency.xOptionxAx
shouldxbexassessedxeveryx15-
20xminutesxduringxlaborxbutxisxnotxspecificxforxAROM.xOptionxBxisxmonitoredxhourlyxafterxt
hexmembranesxarexrupturedxtoxdetectxthexdevelopmentxofxamnionitis.xOptionxDxshouldxbe
xdeterminedxforxallxclientsxinxlabor.
,Sixxhoursxafterxanxoxytocinxinductionxwasxbegunxandx2xhoursxafterxspontaneousxrupturexo
fxthexmembranes,xthexnursexnotesxseveralxsuddenxdecreasesxinxthexfetalxheartxratexwithxq
uickxreturnxtoxbaseline,xwithxandxwithoutxcontractions.xBasedxonxthisxfetalxheartxratexpatter
n,xwhichxinterventionxisxbestxforxthexnursextoximplement?x-xans--
A:xPlacexthexclientxinxaxslightxTrendelenburgxposition.
Rationale:
ThexgoalxisxtoxrelievexpressurexonxthexumbilicalxcordxandxplacingxthexclientxinxaxslightxTren
delenburgxpositionxisxmostxlikelyxtoxrelievexthatxpressure.xThexFHRxpatternxisxindicativexofx
axvariablexfetalxheartxratexdeceleration,xwhichxisxtypicallyxcausedxbyxcordxcompressionxan
dxcanxoccurxwithxorxwithoutxcontractions.xOptionxAxmayxbexhelpfulxtoxincreasexvascularxsp
acexbutxisxnotxasxlikelyxtoxrelievexthexpressurexasxthexTrendelenburgxposition.xOptionxBxisx
notxhelpfulxwithxcordxcompression.xOptionxDxisxnotxthexpriorityxinterventionxatxthisxtime.xAft
erxrepositioningxthexclient,xaxvaginalxexaminationxisxindicatedxtoxrulexoutxcordxprolapsexan
dxassessxforxcervicalxchange.
Axbreastfeedingxpostpartumxclientxisxdiagnosedxwithxmastitis,xandxantibioticxtherapyxisxpre
scribed.xWhichxinstructionxshouldxthexnursexprovidextoxthisxclient?x-xans--
A:xBreastfeedxthexinfant,xensuringxthatxbothxbreastsxarexcompletelyxemptied.
Rationale:
Mastitis,xcausedxbyxpluggedxmilkxducts,xisxrelatedxtoxbreastxengorgement,xandxbreastfeed
ingxduringxmastitisxfacilitatesxthexcompletexemptyingxofxengorgedxbreasts,xeliminatingxthex
pressurexonxthexinflamedxbreastxtissue.xOptionxBxisxlessxpainfulxbutxdoesxnotxfacilitatexco
mpletexemptyingxofxthexbreastxtissue.xOptionxCxwillxnotxrelievexthexengorgementxonxthexaff
ectedxside.xOptionxDxwillxnotxdecreasexantibioticxeffectsxonxthexinfant.
Axnewbornxinfant,xdiagnosedxwithxdevelopmentalxdysplasiaxofxthexhipx(DDH),xisxbeingxpre
paredxforxdischarge.xWhichxnursingxactionxshouldxbexincludedxinxthisxinfant'sxdischargexte
achingxplan?x-xans--A:xObservexthexparentsxapplyingxaxPavlikxharness.x
Rationale:xItxisximportantxthatxthexhipsxofxinfantsxwithxhipxdysplasiaxarexmaintainedxinxanxa
bductedxposition,xwhichxcanxbexaccomplishedxbyxusingxthexPavlikxharness;xthisxkeepsxthe
xhipsxandxkneesxflexed,xthexhipsxabducted,xandxthexfemoralxheadxinxthexacetabulum.xEarly
xtreatmentxoftenxnegatesxthexneedxforxsurgery,xandxoptionxBxisxnotxindicatedxuntilxapproxi
matelyx6xmonthsxofxage.xOptionxCxisxnotxindicatedxforxhipxdysplasia.xItxisxbestxforxthexpedia
tricianxtoxmonitorxhipxjointxmobility,xandxteachingxthexparentsxtoxperformxthisxtechniquexisxli
kelyxtoxincreasextheirxanxiety.
Whenxpreparingxaxclassxonxnewbornxcarexforxexpectantxparents,xwhichxisxcorrectxforxthexn
ursextoxteachxconcerningxthexnewbornxinfantxbornxatxtermxgestation?x-xans--
A:xVernixxisxaxwhitexcheesyxsubstance,xpredominantlyxlocatedxinxthexskinxfolds
Rationale:x
Vernix,xfoundxinxthexfoldsxofxthexskin,xisxaxcharacteristicxofxtermxinfants.xMiliaxarexnotxredx
marksxmadexbyxforcepsxbutxarexwhitexpinpointxspotsxusuallyxfoundxoverxthexnosexandxchin
, xthatxrepresentxblockagexofxthexsebaceousxglands.xMeconiumxisxthexfirstxstool,xbutxitxisxtar
ryxblack,xnotxyellow.xPseudostrabismusx(crossedxeyes)xisxnormalxatxbirthxthroughxthexthird
xorxfourthxmonthxandxdoesxnotxrequirexsurgery.
Clientxteachingxisxanximportantxpartxofxthexperinatalxnurse'sxrole.xWhichxfactorxhasxthexgre
atestxinfluencexonxsuccessfulxteachingxofxthexpregnantxclient?x-xans--
A:xThexclient'sxinvestmentxinxwhatxisxbeingxtaught
Rationale:Whenxteachingxanyxclient,xreadinessxtoxlearnxisxrelatedxtoxhowxmuchxthexclientx
hasxinvestedxinxwhatxisxbeingxtaughtxorxhowximportantxthexmaterialsxarextoxthexclient'sxpart
icularxlife.xForxexample,xthexclientxwithxseverexmorningxsicknessxinxthexfirstxtrimesterxmayx
notxbexreadyxtoxlearnxaboutxlaborxandxdeliveryxbutxisxprobablyxveryxreadyxtoxlearnxaboutxw
aysxtoxrelievexmorningxsickness.xOptionsxBxandxCxarexfactorsxthatxmayxinfluencexlearningx
butxarexnotxasxinfluentialxasxoptionxA.xEvenxifxaxpregnancyxisxplannedxandxveryxdesirable,xt
hexclientxmustxbexreadyxtoxlearnxthexcontentxpresented.
Whenxaxnewxmotherxreceivesxherxinfantxforxthexfirstxtime,xwhichxbehaviorxisxmostxreassuri
ngxtoxthexnurse?x-xans--
A:xHerxarmsxandxhandsxreceivexthexinfant,xandxshexthenxtracesxthexinfant'sxprofilexwithxher
xfingertips.
Rationale:x
Attachmentxandxbondingxtheoryxindicatexthatxmostxmothersxwillxdemonstratexbehaviorsxd
escribedxinxoptionxBxduringxthexfirstxvisitxwithxthexnewborn,xwhichxmayxbexatxdeliveryxorxlat
er.xAfterxthexfirstxvisit,xthexmotherxmayxexhibitxdifferentxtouchingxbehaviorsxsuchxasxeagerl
yxreachingxforxthexinfantxandxcuddlingxthexinfantxclosextoxher.
Whenxassessingxaxclientxatx12xweeksxofxgestation,xthexnursexrecommendsxthatxshexandxh
erxhusbandxconsiderxattendingxchildbirthxpreparationxclasses.xWhenxisxthexbestxtimexforxt
hexcouplextoxattendxthesexclasses?x-xans--A:xAtx30xweeksxofxgestation
Rationale:x
Learningxisxfacilitatedxbyxinterestedxcouple.xThexcouplexisxmostxinterestedxinxchildbirthxto
wardxthexendxofxthexpregnancy,xwhenxtheyxarexbeginningxtoxanticipatexthexonsetxofxlaborx
andxthexbirthxofxtheirxchild.xOptionxDxisxclosestxtoxthextimexwhenxparentsxwouldxbexreadyxf
orxsuchxclasses.xOptionsxA,xB,xandxCxarexnotxthexbestxtimesxduringxaxpregnancyxforxthexco
uplextoxattendxchildbirthxeducationxclasses.xAtxthesextimesxtheyxwillxhavexotherxteachingxn
eeds.xEarlyxpregnancyxclassesxoftenxincludextopicsxsuchxasxnutrition,xphysiologicxchange
s,xcopingxwithxnormalxdiscomfortsxofxpregnancy,xfetalxdevelopment,xmaternalxandxfetalxris
kxfactors,xandxevolvingxrolesxofxthexmotherxandxherxsignificantxothers
Anxexpectantxfatherxtellsxthexnursexhexisxconcernedxaboutxsomexofxhisxwife'sxbehaviors.xH
exstatesxthatxshexisxconstantlyxrubbingxherxabdomenxandxtalkingxtoxthexbaby.xWhichxreco
mmendationxshouldxthexnursexmakextoxthisxexpectantxfather?x-xans--
A:xReassurexhimxthatxnormalxmaternal-fetalxbondingxisxoccurring.x
