HESI Comprehensive Exam: Tested Strategies,
Superior Questions, & Expert Solutions for
Guaranteed Success
A nurse is caring for a client who sustained a missed abortion during the second trimester
of pregnancy. For which finding indicating the need for further evaluation does the nurse
monitor the client?
Spontaneous bruising
Decrease in uterine siz
Urine output of 30 mL/hr
Brownish vaginal discharge - CORRECT ANS- -Spontaneous bruising
Rationale: A major complication of a missed abortion is disseminated intravascular
coagulation (DIC). Bleeding at the sites of intravenous needle insertion or laboratory blood
draws, nosebleeds, and spontaneous bruising may be early indicators of DIC; they should
be reported and require further evaluation. Missed abortion is the term used to describe
when a fetus dies during the first half of pregnancy but is retained in the uterus. When the
fetus dies, the early signs/symptoms of pregnancy (e.g., nausea, breast tenderness, urinary
frequency) disappear. The uterus stops growing and begins to shrink. Red or brownish
vaginal bleeding may or may not occur.
A client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse
monitoring the client notes uterine hypertonicity. What does the nurse immediately do?
Stop the oxytocin infusion
Check the vagina for crowning
Encourage the client to take short, deep breaths
Increase the rate of the oxytocin infusion and call the primary health care provider -
CORRECT ANS- -Stop the oxytocin infusion
,Rationale: The nurse would immediately stop the oxytocin infusion and increase the rate of
the nonadditive solution, position the client in a side-lying position, and administer oxygen
with the use of a snug face mask at 8 to 10 L/min. If uterine hypertonicity or a
nonreassuring fetal heart rate pattern is detected, the nurse must intervene to reduce
uterine activity and increase fetal oxygenation. The nurse would also notify the primary
health care provider. Oxytocin is a synthetic compound identical to the natural hormone
secreted from the posterior pituitary gland. It is used to induce or augment labor at or near
term. The nurse monitors uterine activity for the establishment of an effective labor pattern
and for complications associated with the use of the medication. Checking the vagina for
crowning; encouraging the client to take short, deep breaths; and increasing the rate of the
oxytocin infusion are not the immediate actions.
A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor
tracing (see figure). Which action should the nurse take as a result of this observation?
Reposition the mother
Document the finding
Notify the nurse-midwife
Take the mother's vital signs - CORRECT ANS- -Document the finding
Rationale: The nurse sees evidence of accelerations. Accelerations are transient increases
in the fetal heart rate that often accompany contractions and are normally caused by fetal
movement. Ths nurse should document the finding. Accelerations are thought to be a sign
of fetal well-being and adequate oxygen reserve. Repositioning the mother, notifying the
nurse-midwife, and taking the mother's vital signs are all unnecessary actions.
A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse
effect of cisplatin will the nurse assess the client?
Nausea
, Bloody urine
Hearing loss
Electrocardiographic changes - CORRECT ANS- -Hearing loss
Rationale: Cisplatin is a platinum-based agent used to treat various types of cancer. One
adverse effect of cisplatin is ototoxicity, and the nurse would monitor the client for tinnitus
and hearing loss. Nausea occurs with the use of several chemotherapeutic agents and is
not necessarily an adverse effect. Cyclophosphamide causes hemorrhagic cystitis,
evidenced by bloody urine. Doxorubicin (Adriamycin) causes cardiotoxicity.
A nurse is monitoring a pregnant client with suspected partial placenta previa who is
experiencing vaginal bleeding. Which finding would the nurse expect to note on
assessment of the client?
Painful vaginal bleeding
Sustained tetanic contractions
Complaints of abdominal pain
Soft, relaxed, nontender uterus - CORRECT ANS- -Soft, relaxed, nontender uterus
Rationale: Partial placenta previa is incomplete coverage of the internal os by the placenta.
One characteristic of placenta previa is painless vaginal bleeding. The abdominal
assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal
bleeding and uterine pain and tenderness accompany placental abruption, especially with
a central abruption and blood trapped behind the placenta. In placental abruption, the
abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium,
resulting in pain and uterine irritability. A sustained tetanic contraction may occur if the
client is in labor and the uterine muscle cannot relax.
A nurse assisting with a delivery is monitoring the client for placental separation after the
delivery of a viable newborn. Which observation indicates to the nurse that placental
separation has occurred?
Superior Questions, & Expert Solutions for
Guaranteed Success
A nurse is caring for a client who sustained a missed abortion during the second trimester
of pregnancy. For which finding indicating the need for further evaluation does the nurse
monitor the client?
Spontaneous bruising
Decrease in uterine siz
Urine output of 30 mL/hr
Brownish vaginal discharge - CORRECT ANS- -Spontaneous bruising
Rationale: A major complication of a missed abortion is disseminated intravascular
coagulation (DIC). Bleeding at the sites of intravenous needle insertion or laboratory blood
draws, nosebleeds, and spontaneous bruising may be early indicators of DIC; they should
be reported and require further evaluation. Missed abortion is the term used to describe
when a fetus dies during the first half of pregnancy but is retained in the uterus. When the
fetus dies, the early signs/symptoms of pregnancy (e.g., nausea, breast tenderness, urinary
frequency) disappear. The uterus stops growing and begins to shrink. Red or brownish
vaginal bleeding may or may not occur.
A client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse
monitoring the client notes uterine hypertonicity. What does the nurse immediately do?
Stop the oxytocin infusion
Check the vagina for crowning
Encourage the client to take short, deep breaths
Increase the rate of the oxytocin infusion and call the primary health care provider -
CORRECT ANS- -Stop the oxytocin infusion
,Rationale: The nurse would immediately stop the oxytocin infusion and increase the rate of
the nonadditive solution, position the client in a side-lying position, and administer oxygen
with the use of a snug face mask at 8 to 10 L/min. If uterine hypertonicity or a
nonreassuring fetal heart rate pattern is detected, the nurse must intervene to reduce
uterine activity and increase fetal oxygenation. The nurse would also notify the primary
health care provider. Oxytocin is a synthetic compound identical to the natural hormone
secreted from the posterior pituitary gland. It is used to induce or augment labor at or near
term. The nurse monitors uterine activity for the establishment of an effective labor pattern
and for complications associated with the use of the medication. Checking the vagina for
crowning; encouraging the client to take short, deep breaths; and increasing the rate of the
oxytocin infusion are not the immediate actions.
A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor
tracing (see figure). Which action should the nurse take as a result of this observation?
Reposition the mother
Document the finding
Notify the nurse-midwife
Take the mother's vital signs - CORRECT ANS- -Document the finding
Rationale: The nurse sees evidence of accelerations. Accelerations are transient increases
in the fetal heart rate that often accompany contractions and are normally caused by fetal
movement. Ths nurse should document the finding. Accelerations are thought to be a sign
of fetal well-being and adequate oxygen reserve. Repositioning the mother, notifying the
nurse-midwife, and taking the mother's vital signs are all unnecessary actions.
A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse
effect of cisplatin will the nurse assess the client?
Nausea
, Bloody urine
Hearing loss
Electrocardiographic changes - CORRECT ANS- -Hearing loss
Rationale: Cisplatin is a platinum-based agent used to treat various types of cancer. One
adverse effect of cisplatin is ototoxicity, and the nurse would monitor the client for tinnitus
and hearing loss. Nausea occurs with the use of several chemotherapeutic agents and is
not necessarily an adverse effect. Cyclophosphamide causes hemorrhagic cystitis,
evidenced by bloody urine. Doxorubicin (Adriamycin) causes cardiotoxicity.
A nurse is monitoring a pregnant client with suspected partial placenta previa who is
experiencing vaginal bleeding. Which finding would the nurse expect to note on
assessment of the client?
Painful vaginal bleeding
Sustained tetanic contractions
Complaints of abdominal pain
Soft, relaxed, nontender uterus - CORRECT ANS- -Soft, relaxed, nontender uterus
Rationale: Partial placenta previa is incomplete coverage of the internal os by the placenta.
One characteristic of placenta previa is painless vaginal bleeding. The abdominal
assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal
bleeding and uterine pain and tenderness accompany placental abruption, especially with
a central abruption and blood trapped behind the placenta. In placental abruption, the
abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium,
resulting in pain and uterine irritability. A sustained tetanic contraction may occur if the
client is in labor and the uterine muscle cannot relax.
A nurse assisting with a delivery is monitoring the client for placental separation after the
delivery of a viable newborn. Which observation indicates to the nurse that placental
separation has occurred?
