Maternity HESI Case Study Questions
with correct answers
A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started on IV
magnesium sulfate after being diagnosed with severe preeclampsia. After determining
the serum magnesium level to be 15 mEq/L, the nurse should expect which of the
following manifestations in the client?
ECG changes.
Loss of reflexes.
Respiratory distress.
Cardiac arrest. - CORRECT ANSWERS-Respiratory distress
--> The therapeutic level of magnesium sulfate is 4 to 7 mEq/L. ECG changes occur at 5
to 10 mEq/L. Loss of reflexes is unavoidable at 8 to 12 mEq/L. At 15 mEq/L, the client
may experience respiratory distress. At 25 mEq/L, cardiac arrest may occur.
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation
in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which
assessment is the highest priority for the nurse to monitor during the administration of
this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes. - CORRECT ANSWERS-Maternal and fetal heart rates.
--> Terbutaline has effects on receptors. It acts as a sympathomimetic agent stimulating
beta 1 receptors which cause tachycardia as a side effect and that is a reason why
monitoring maternal and fetal heart rates is most important when terbutaline is being
administered. It also affects beta 2 receptors which relaxes the uterus and that is the
reason for its administration.
,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?
Deep tendon reflexes 2+.
Blood pressure 140/90.
Respiratory rate 18/minute.
Urine output 90 ml/4 hours. - CORRECT ANSWERS-Urine output 90 ml/4 hours.
--> MAG TOX = urine outputs of less than 100 ml/4 hours, absent DTRs, and a
respiratory rate of less than 12 breaths/minute
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in her lower back. Which intervention should
the nurse implement? - CORRECT ANSWERS-firm pressure to sacrum
A client at 28 weeks' gestation is asking for a laxative for constipation. What action
would the nurse recommend? - CORRECT ANSWERS-Fiber rich foods
--> Laxatives, suppositories, and enemas only provide temporary relief and may
stimulate labor.
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?
Come to the clinic today for an ultrasound.
Go immediately to the emergency room.
Lie on your left side for about one hour and see if the bleeding stops.
Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract
infection. - CORRECT ANSWERS-Come to the clinic today for an ultrasound.
--> bright red blood in 3rd trimester could be placenta previa
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control
the symptoms. Which assessment finding would indicate that therapeutic drug level has
been achieved?
4+ reflexes.
Urinary output of 50 ml per hour.
A decrease in respiratory rate from 24 to 16.
A decreased body temperature. - CORRECT ANSWERS-A decrease in respiratory rate
from 24 to 16.
, --> Magnesium sulfate is a CNS depressant that helps prevent seizures. A decreased
respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates
toxic effects.) The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6
mg/dl.
A client at 9 weeks' gestation asks the nurse, "What is a diagonal conjugate?" What is
the nurse's best response? - CORRECT ANSWERS-measurement to see if pelvis is
adequate for vaginal delivery
A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the
bones at the back of the head of her newborn. The attending nurse informs the client
that it is the posterior fontanel (fontanelle). The client is anxious to know when the
posterior fontanel (fontanelle) will close. Which time span is the normal duration for the
closure of the posterior fontanel (fontanelle)? - CORRECT ANSWERS-8 - 12 weeks
A client in active labor is admitted with preeclampsia. Which assessment finding is most
significant in planning this client's care?
Patellar reflex 4+.
Blood pressure 158/80.
Four-hour urine output 240 ml.
Respiration 12/minute. - CORRECT ANSWERS-Patellar reflex 4+.
--> A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia,
which is an indication of an impending seizure.
A client in her first trimester is concerned about how weight gain will affect her
appearance and questions the nurse concerning dietary restrictions. How much weight
gain should the nurse point out will be safe for this client with a low BMI? - CORRECT
ANSWERS-28 to 40 pounds
The recommendation for average weight gain is 25 to 35 lbs (11 to 16 kilograms).
The woman who is underweight with a low BMI should gain 28 to 40 pounds (13 to 18
kilograms).
Individuals with a high BMI should gain 15 to 25 pounds (7 to 11 kilograms).
A client in latent labor for the past 12 hours is requesting medication to help her rest.
The nurse predicts the health care provider will prescribe which medication?
meperidine
secobarbital
fentanyl
morphine - CORRECT ANSWERS-secobarbital
with correct answers
A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started on IV
magnesium sulfate after being diagnosed with severe preeclampsia. After determining
the serum magnesium level to be 15 mEq/L, the nurse should expect which of the
following manifestations in the client?
ECG changes.
Loss of reflexes.
Respiratory distress.
Cardiac arrest. - CORRECT ANSWERS-Respiratory distress
--> The therapeutic level of magnesium sulfate is 4 to 7 mEq/L. ECG changes occur at 5
to 10 mEq/L. Loss of reflexes is unavoidable at 8 to 12 mEq/L. At 15 mEq/L, the client
may experience respiratory distress. At 25 mEq/L, cardiac arrest may occur.
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation
in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which
assessment is the highest priority for the nurse to monitor during the administration of
this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes. - CORRECT ANSWERS-Maternal and fetal heart rates.
--> Terbutaline has effects on receptors. It acts as a sympathomimetic agent stimulating
beta 1 receptors which cause tachycardia as a side effect and that is a reason why
monitoring maternal and fetal heart rates is most important when terbutaline is being
administered. It also affects beta 2 receptors which relaxes the uterus and that is the
reason for its administration.
,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?
Deep tendon reflexes 2+.
Blood pressure 140/90.
Respiratory rate 18/minute.
Urine output 90 ml/4 hours. - CORRECT ANSWERS-Urine output 90 ml/4 hours.
--> MAG TOX = urine outputs of less than 100 ml/4 hours, absent DTRs, and a
respiratory rate of less than 12 breaths/minute
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in her lower back. Which intervention should
the nurse implement? - CORRECT ANSWERS-firm pressure to sacrum
A client at 28 weeks' gestation is asking for a laxative for constipation. What action
would the nurse recommend? - CORRECT ANSWERS-Fiber rich foods
--> Laxatives, suppositories, and enemas only provide temporary relief and may
stimulate labor.
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?
Come to the clinic today for an ultrasound.
Go immediately to the emergency room.
Lie on your left side for about one hour and see if the bleeding stops.
Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract
infection. - CORRECT ANSWERS-Come to the clinic today for an ultrasound.
--> bright red blood in 3rd trimester could be placenta previa
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control
the symptoms. Which assessment finding would indicate that therapeutic drug level has
been achieved?
4+ reflexes.
Urinary output of 50 ml per hour.
A decrease in respiratory rate from 24 to 16.
A decreased body temperature. - CORRECT ANSWERS-A decrease in respiratory rate
from 24 to 16.
, --> Magnesium sulfate is a CNS depressant that helps prevent seizures. A decreased
respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates
toxic effects.) The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6
mg/dl.
A client at 9 weeks' gestation asks the nurse, "What is a diagonal conjugate?" What is
the nurse's best response? - CORRECT ANSWERS-measurement to see if pelvis is
adequate for vaginal delivery
A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the
bones at the back of the head of her newborn. The attending nurse informs the client
that it is the posterior fontanel (fontanelle). The client is anxious to know when the
posterior fontanel (fontanelle) will close. Which time span is the normal duration for the
closure of the posterior fontanel (fontanelle)? - CORRECT ANSWERS-8 - 12 weeks
A client in active labor is admitted with preeclampsia. Which assessment finding is most
significant in planning this client's care?
Patellar reflex 4+.
Blood pressure 158/80.
Four-hour urine output 240 ml.
Respiration 12/minute. - CORRECT ANSWERS-Patellar reflex 4+.
--> A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia,
which is an indication of an impending seizure.
A client in her first trimester is concerned about how weight gain will affect her
appearance and questions the nurse concerning dietary restrictions. How much weight
gain should the nurse point out will be safe for this client with a low BMI? - CORRECT
ANSWERS-28 to 40 pounds
The recommendation for average weight gain is 25 to 35 lbs (11 to 16 kilograms).
The woman who is underweight with a low BMI should gain 28 to 40 pounds (13 to 18
kilograms).
Individuals with a high BMI should gain 15 to 25 pounds (7 to 11 kilograms).
A client in latent labor for the past 12 hours is requesting medication to help her rest.
The nurse predicts the health care provider will prescribe which medication?
meperidine
secobarbital
fentanyl
morphine - CORRECT ANSWERS-secobarbital
