HESI REVISED QUESTIONS
/CORRECT ANSWERS /GRADED A+
What action should the nurse implement with the family when an infant is born
with anencephaly?
Ensure that measures to facilitate the attachment process are offered.
Prepare the family to explore ways to cope with the imminent death of the infant.
Inform the family about multiple corrective surgical procedures that will be
needed.
Provide emotional support to facilitate the consideration of fetal organ donation. -
ANSWER-B
Anencephaly, a neural tube congenital malformation, is the incomplete
embryological formation of both cerebral hemispheres, which often results in death
due to respiratory failure. While comfort measures are provided, there is no
resuscitation effort or successful treatment available, so the family should be
prepared for the infant's imminent death (B) and encouraged to explore ways to
cope with the loss and express grief. Providing opportunities with the infant
promote a realistic experience of connectedness and facilitates parental closure, not
attachment (A). (C) is not warranted. Although (D) may be considered, it may not
,be the most therapeutic family-centered intervention when initially confronting the
parents with the infant's prognosis.
Which prescription should the nurse administer to a newborn to reduce
complications related to birth trauma?
Silver nitrate.
Erythromycin (Ilotycin ointment).
Ceftriaxone (Rocephin).
Vitamin K (AquaMEPHYTON). - ANSWER-D
The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels
and reduce the risk of neonatal bleeding, newborns receive a single injection of
vitamin K (AquaMEPHYTON) (D). (A and B) are prophylactic ophthalmic agents
used to prevent neonatal ophthalmia. (C) is an antibiotic used to treat neonatal
infections.
Which behavior should the nurse anticipate for a new mother with an
uncomplicated vaginal birth on the third postpartum day?
Request help with ambulation and perineal care.
Exhibit interest in learning more about infant care.
,Sleep most of the time when the baby is not present.
Be very excited and talkative about the birth experience. - ANSWER-B
By the third postpartum day, the new mother should start to "take hold" of caring
for her infant, by asking questions about infant care and initiating care of her infant
(B). This client should be independent with self-care (A). Excessive sleeping (C) is
more indicative of immediate post-delivery behavior when the new mother is tired
from the process of labor. Being excited and talkative about the birth is more
characteristic of "taking in" behavior, seen in the first 24 to 48 hours after delivery
(D).
A multiparous client is experiencing bleeding 2 hours after a vaginal delivery.
What action should the nurse implement next?
Determine the firmness of the fundus.
Give oxytocin (Pitocin) intravenously.
Inform the healthcare provider of the bleeding.
Assess the vital signs for indicators of shock. - ANSWER-A
The first step in recognizing the potential cause of postpartum bleeding is to
evaluate the contractility of the uterus (A). (B) should not be implemented until the
cause of the bleeding is determined. The nurse should implement (C) after
, completing the assessment of the potential cause for bleeding. (D) is important, but
(A) is a higher priority.
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her
last menstrual period began on February 15, and that previously her periods were
regular. Her pregnancy test is positive. This client's expected date of delivery
(EDD) would be
November 22.
November 8.
December 22.
October 22. - ANSWER-A
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. - ANSWER-C
The nurse identifies crepitus when examining the chest of a newborn who was
delivered vaginally. Which further assessment should the nurse perform?
Elicit a positive scarf sign on the affected side.
/CORRECT ANSWERS /GRADED A+
What action should the nurse implement with the family when an infant is born
with anencephaly?
Ensure that measures to facilitate the attachment process are offered.
Prepare the family to explore ways to cope with the imminent death of the infant.
Inform the family about multiple corrective surgical procedures that will be
needed.
Provide emotional support to facilitate the consideration of fetal organ donation. -
ANSWER-B
Anencephaly, a neural tube congenital malformation, is the incomplete
embryological formation of both cerebral hemispheres, which often results in death
due to respiratory failure. While comfort measures are provided, there is no
resuscitation effort or successful treatment available, so the family should be
prepared for the infant's imminent death (B) and encouraged to explore ways to
cope with the loss and express grief. Providing opportunities with the infant
promote a realistic experience of connectedness and facilitates parental closure, not
attachment (A). (C) is not warranted. Although (D) may be considered, it may not
,be the most therapeutic family-centered intervention when initially confronting the
parents with the infant's prognosis.
Which prescription should the nurse administer to a newborn to reduce
complications related to birth trauma?
Silver nitrate.
Erythromycin (Ilotycin ointment).
Ceftriaxone (Rocephin).
Vitamin K (AquaMEPHYTON). - ANSWER-D
The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels
and reduce the risk of neonatal bleeding, newborns receive a single injection of
vitamin K (AquaMEPHYTON) (D). (A and B) are prophylactic ophthalmic agents
used to prevent neonatal ophthalmia. (C) is an antibiotic used to treat neonatal
infections.
Which behavior should the nurse anticipate for a new mother with an
uncomplicated vaginal birth on the third postpartum day?
Request help with ambulation and perineal care.
Exhibit interest in learning more about infant care.
,Sleep most of the time when the baby is not present.
Be very excited and talkative about the birth experience. - ANSWER-B
By the third postpartum day, the new mother should start to "take hold" of caring
for her infant, by asking questions about infant care and initiating care of her infant
(B). This client should be independent with self-care (A). Excessive sleeping (C) is
more indicative of immediate post-delivery behavior when the new mother is tired
from the process of labor. Being excited and talkative about the birth is more
characteristic of "taking in" behavior, seen in the first 24 to 48 hours after delivery
(D).
A multiparous client is experiencing bleeding 2 hours after a vaginal delivery.
What action should the nurse implement next?
Determine the firmness of the fundus.
Give oxytocin (Pitocin) intravenously.
Inform the healthcare provider of the bleeding.
Assess the vital signs for indicators of shock. - ANSWER-A
The first step in recognizing the potential cause of postpartum bleeding is to
evaluate the contractility of the uterus (A). (B) should not be implemented until the
cause of the bleeding is determined. The nurse should implement (C) after
, completing the assessment of the potential cause for bleeding. (D) is important, but
(A) is a higher priority.
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her
last menstrual period began on February 15, and that previously her periods were
regular. Her pregnancy test is positive. This client's expected date of delivery
(EDD) would be
November 22.
November 8.
December 22.
October 22. - ANSWER-A
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. - ANSWER-C
The nurse identifies crepitus when examining the chest of a newborn who was
delivered vaginally. Which further assessment should the nurse perform?
Elicit a positive scarf sign on the affected side.
