HESI MILESTONE EXAM 2 MEDSURG
2/OB/PEDS QUESTIONS & ANSWERS
Sickle cells sign of crisis: - ANSWERSpain and fatigue, swollen hands and feet,
dehydration, give oxygen, fluids, pain medication, infection prevention. Child is pale and
listless Abdominal pain. Fever Severe abdominal pain. Hand-foot syndrome (infants);
painful edematous hands and feeT. Arthralgia
Infant congenital heart defect assessment: - ANSWERSobtain health history, color
changes associated with feedings, activity, or crying. Look for the child's skin color.
Murmur, frequent respiratory infection, cyanosis, regurgitation.
RSV distress: - ANSWERSfirst sign of distress is tachypnea, coughing, sneezing, fever,
wheezing, prolonged expiration
Pyloric stenosis s/s: - ANSWERSforceful, non billous vomiting that is unrelated to
feeding position, hunger as soon as vomiting is over, weight loss, progressive
dehydration, positive family history, Palpable olive-shaped mass in upper-right quadrant
of the abdomen, Metabolic alkalosis (decreased serum chloride, increased pH and
bicarbonate or CO2 content, hydration with decreased sodium and potassium
Intussusception: - ANSWERSbowel 'telescopes' into the bowel causing edema or total
bowel obstruction, s/s include: creaming, with legs drawn up to abdomen, sudden onset
of severe cramping, severe pain, vomiting, diarrhea, Currant-jelly stools, gross blood, or
hemoccult-positive stools, Lethargy. immediately report the presence of bilious vomiting,
and sausage like mass on top of the stomach. Management: administer IV fluids and
antibiotics
Vomiting and diarrhea infant: - ANSWERSusually caused by virus, need to restore
electrolytes,
Placental abruptio - ANSWERSn: s/s are painful, dark red bleeding, uterine tenderness,
decreased fetal movement, place woman on a left lateral position to prevent pressure
, on vena cava, admin oxygen, look at vital signs for hypovolemic shock, assess fundal
height (higher increase bleeding)
Fetal rate tachycardia: - ANSWERSgreater than 160 for 10 minutes or longer. -Caused
by decreased fetal oxygen supply, Turn client onto left side Discontinue oxytocin
(Pitocin) if infused. Administer O2 at 10 L by a tight facemask. Bolus IV fluids Notify
health care provide
Umbilical cord prolapse: - ANSWERSfetal hypoxia occurs, lay woman down, hold the
presenting part off the cord to relieve compression, knee to chest, admin oxygen and
prepare for c section
Shoulder dystocia: - ANSWERSfetal descent and birth by the axis of the fetal shoulders
after the fetal head has been delivered. Perform mcroberts maneuver, Suprapubic
pressure. Risk factors include size discrepancies, obesity, uterine abnormalities,
FHR decels: - ANSWERSearly decels do not require intervention, No nursing
interventions are required except to monitor the progress of labor. Document the
processes of labor. late decels are usually caused by uteroplacental insufficiency. Heart
rate slowly and smoothly decelerates at beginning of contraction and returns to baseline
at end of contraction
Nursing interventions for late decels: - ANSWERSurn client to left side, discount pitocin,
admin oxy, maintain IV fluids, elevate legs to promote venous return, notify hcp
Variable decels: - ANSWERS-Repositioning of the mother can relieve this compression
if it is minor Administer oxygen Stop Oxytocin (Pitocin) Check for vaginal cord prolapse
Postpartum hemorrhage: - ANSWERS5 T: tone, tissue, trauma, thrombin, traction. After
birth is immediate fundal massage, IV fluids, admin uterotonic drugs (Oxytocin (Pitocin);
misoprostol (Cytotec); dinoprostone (Prostin E2); methylergonovine maleate
(Methergine); and a derivative of prostaglandin (PGF2α), carboprost (Hemabate). Keep
bladder empty
Engorgement: - ANSWERSpostnatal physiologic painful condition in which distention
and swelling of the breast tissue occurs as a result of an increase in blood and lymph
supply as a precursor to lactation. Usually peaks within 4-5 days postpartum. Apply heat
or cold compress, breast massage, milk expression, ultrasound, breast pumping, and
antiinflammatory agents
Cystic fibrosis complications - ANSWERS: Lung insufficiency (most critical problem).
ALWAYS MONITOR RESP. hemoptysis, pneumothorax, bacterial colonization, cor
pulmonale, volvulus, intussusception, intestinal obstruction, rectal prolapse,
gastroesophageal reflux disease, diabetes, portal hypertension, liver failure, gallstones,
and decreased fertility. Avoid lung infections, wash hands,
2/OB/PEDS QUESTIONS & ANSWERS
Sickle cells sign of crisis: - ANSWERSpain and fatigue, swollen hands and feet,
dehydration, give oxygen, fluids, pain medication, infection prevention. Child is pale and
listless Abdominal pain. Fever Severe abdominal pain. Hand-foot syndrome (infants);
painful edematous hands and feeT. Arthralgia
Infant congenital heart defect assessment: - ANSWERSobtain health history, color
changes associated with feedings, activity, or crying. Look for the child's skin color.
Murmur, frequent respiratory infection, cyanosis, regurgitation.
RSV distress: - ANSWERSfirst sign of distress is tachypnea, coughing, sneezing, fever,
wheezing, prolonged expiration
Pyloric stenosis s/s: - ANSWERSforceful, non billous vomiting that is unrelated to
feeding position, hunger as soon as vomiting is over, weight loss, progressive
dehydration, positive family history, Palpable olive-shaped mass in upper-right quadrant
of the abdomen, Metabolic alkalosis (decreased serum chloride, increased pH and
bicarbonate or CO2 content, hydration with decreased sodium and potassium
Intussusception: - ANSWERSbowel 'telescopes' into the bowel causing edema or total
bowel obstruction, s/s include: creaming, with legs drawn up to abdomen, sudden onset
of severe cramping, severe pain, vomiting, diarrhea, Currant-jelly stools, gross blood, or
hemoccult-positive stools, Lethargy. immediately report the presence of bilious vomiting,
and sausage like mass on top of the stomach. Management: administer IV fluids and
antibiotics
Vomiting and diarrhea infant: - ANSWERSusually caused by virus, need to restore
electrolytes,
Placental abruptio - ANSWERSn: s/s are painful, dark red bleeding, uterine tenderness,
decreased fetal movement, place woman on a left lateral position to prevent pressure
, on vena cava, admin oxygen, look at vital signs for hypovolemic shock, assess fundal
height (higher increase bleeding)
Fetal rate tachycardia: - ANSWERSgreater than 160 for 10 minutes or longer. -Caused
by decreased fetal oxygen supply, Turn client onto left side Discontinue oxytocin
(Pitocin) if infused. Administer O2 at 10 L by a tight facemask. Bolus IV fluids Notify
health care provide
Umbilical cord prolapse: - ANSWERSfetal hypoxia occurs, lay woman down, hold the
presenting part off the cord to relieve compression, knee to chest, admin oxygen and
prepare for c section
Shoulder dystocia: - ANSWERSfetal descent and birth by the axis of the fetal shoulders
after the fetal head has been delivered. Perform mcroberts maneuver, Suprapubic
pressure. Risk factors include size discrepancies, obesity, uterine abnormalities,
FHR decels: - ANSWERSearly decels do not require intervention, No nursing
interventions are required except to monitor the progress of labor. Document the
processes of labor. late decels are usually caused by uteroplacental insufficiency. Heart
rate slowly and smoothly decelerates at beginning of contraction and returns to baseline
at end of contraction
Nursing interventions for late decels: - ANSWERSurn client to left side, discount pitocin,
admin oxy, maintain IV fluids, elevate legs to promote venous return, notify hcp
Variable decels: - ANSWERS-Repositioning of the mother can relieve this compression
if it is minor Administer oxygen Stop Oxytocin (Pitocin) Check for vaginal cord prolapse
Postpartum hemorrhage: - ANSWERS5 T: tone, tissue, trauma, thrombin, traction. After
birth is immediate fundal massage, IV fluids, admin uterotonic drugs (Oxytocin (Pitocin);
misoprostol (Cytotec); dinoprostone (Prostin E2); methylergonovine maleate
(Methergine); and a derivative of prostaglandin (PGF2α), carboprost (Hemabate). Keep
bladder empty
Engorgement: - ANSWERSpostnatal physiologic painful condition in which distention
and swelling of the breast tissue occurs as a result of an increase in blood and lymph
supply as a precursor to lactation. Usually peaks within 4-5 days postpartum. Apply heat
or cold compress, breast massage, milk expression, ultrasound, breast pumping, and
antiinflammatory agents
Cystic fibrosis complications - ANSWERS: Lung insufficiency (most critical problem).
ALWAYS MONITOR RESP. hemoptysis, pneumothorax, bacterial colonization, cor
pulmonale, volvulus, intussusception, intestinal obstruction, rectal prolapse,
gastroesophageal reflux disease, diabetes, portal hypertension, liver failure, gallstones,
and decreased fertility. Avoid lung infections, wash hands,
