HESI MILESTONE EXAM 2 MEDSURG
2/OB/PEDS AND ANSWERS GRADED
A+.
Sickle cells sign of crisis: - Answer pain 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: - Answer obtain 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: - Answer first sign of distress is tachypnea, coughing, sneezing, fever, wheezing, prolonged
expiration
Pyloric stenosis s/s: - Answer forceful, 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: - Answer bowel '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: - Answer usually caused by virus, need to restore electrolytes,
Placental abruptio - Answer n: 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: - Answer greater 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: - Answer fetal 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: - Answer fetal 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: - Answer early 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: - Answer urn client to left side, discount pitocin, admin oxy,
maintain IV fluids, elevate legs to promote venous return, notify hcp
Variable decels: - Answer -Repositioning of the mother can relieve this compression if it is minor
Administer oxygen Stop Oxytocin (Pitocin) Check for vaginal cord prolapse
Postpartum hemorrhage: - Answer 5 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: - Answer postnatal 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 - Answer : Lung insufficiency (most critical problem). ALWAYS MONITOR
RESP. hemoptysis, pneumothorax, bacterial colonization, cor pulmonale, volvulus, intussusception,
2/OB/PEDS AND ANSWERS GRADED
A+.
Sickle cells sign of crisis: - Answer pain 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: - Answer obtain 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: - Answer first sign of distress is tachypnea, coughing, sneezing, fever, wheezing, prolonged
expiration
Pyloric stenosis s/s: - Answer forceful, 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: - Answer bowel '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: - Answer usually caused by virus, need to restore electrolytes,
Placental abruptio - Answer n: 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: - Answer greater 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: - Answer fetal 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: - Answer fetal 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: - Answer early 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: - Answer urn client to left side, discount pitocin, admin oxy,
maintain IV fluids, elevate legs to promote venous return, notify hcp
Variable decels: - Answer -Repositioning of the mother can relieve this compression if it is minor
Administer oxygen Stop Oxytocin (Pitocin) Check for vaginal cord prolapse
Postpartum hemorrhage: - Answer 5 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: - Answer postnatal 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 - Answer : Lung insufficiency (most critical problem). ALWAYS MONITOR
RESP. hemoptysis, pneumothorax, bacterial colonization, cor pulmonale, volvulus, intussusception,
