NSG 432 HESI QUESTIONS AND
ANSWERS GRADED A+
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood
pressure drops from 120/80 to 90/60. What action will the nurse take?
A. Notify the healthcare provider or anesthesiologist immediately.
B. Continue to assess the blood pressure q5 minutes.
C. Place the woman in a lateral position.
D. Turn off the continuous epidural. - ANS ✔✔Place the woman in a lateral position.
Rationale
The nurse should immediately turn the woman to a lateral position, place a pillow or wedge
under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and
administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if
it further decreases, the anesthesiologist/healthcare provider should be notified immediately.
A client receiving epidural anesthesia begins to experience nausea and becomes pale and
clammy. What intervention should the nurse implement first?
A. Raise the foot of the bed.
B. Assess for vaginal bleeding.
C. Evaluate the fetal heart rate.
,D. Take the client's blood pressure. - ANS ✔✔Raise the foot of the bed.
Rationale
These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia.
Raising the foot of the bed will increase venous return and provide blood to the vital areas.
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?
A. Discontinue the oxytocin (Pitocin) infusion.
B. Place the client in a semi-Fowler's position.
C. Inform the healthcare provider.
D. Apply firm pressure to sacral area. - ANS ✔✔Apply firm pressure to sacral area.
Rationale
The discomfort of "back labor" can be minimized by the application of firm pressure to the
sacral area.
In developing a teaching plan for expectant parents, the nurse plans to include information
about when the parents can expect the infant's fontanels to close. The nurse bases the
explanation on knowledge that for the normal newborn, the
A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
,D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second
month. - ANS ✔✔anterior fontanel closes at 12 to 18 months and the posterior by the end of
the second month.
Rationale
In the normal infant the anterior fontanel closes at 12 to 18 months of age and the posterior
fontanel by the end of the second month .
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In
which sequence should the nurse implement these nursing actions? (Place the first action on
top and last action on the bottom.)
1.
Reposition the client.
2.
Provide oxygen via face mask.
3.
Increase IV fluid.
4.
Call the healthcare provider. - ANS ✔✔1.
Reposition the client.
2.
Increase IV fluid.
3.
Provide oxygen via face mask.
4.
Call the healthcare provider.
, Rationale
To stabilize the fetus, intrauterine resuscitation becomes the first priority. In order to enhance
the fetal blood supply, the laboring client should be repositioned to displace the gravid uterus
and improve fetal perfusion. Secondly, the IV fluids should be increased to expand the maternal
circulating blood volume. The next step to optimize oxygenation of the circulatory blood volume
is to apply oxygen via face to the mother. Finally, the last step is to notify the primary healthcare
provider for additional interventions to resolve the fetal stress.
When evaluating maternal bonding, which of the following maternal behaviors exhibited by the
client would the nurse most likely expect to see when a new mother receives her infant for the
first time?
A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
B. Her arms and hands receive the infant and she then traces the infant's profile with her
fingertips.
C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
D. She eagerly reaches for the infant and then holds the infant close to her own body. - ANS
✔✔Her arms and hands receive the infant and she then traces the infant's profile with her
fingertips.
Rationale
Attachment/bonding theory indicates that most mothers will demonstrate behaviors such as
tracing the infant's profile with her fingertips during the initial visit with the newborn, which
may be at delivery or later.
ANSWERS GRADED A+
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood
pressure drops from 120/80 to 90/60. What action will the nurse take?
A. Notify the healthcare provider or anesthesiologist immediately.
B. Continue to assess the blood pressure q5 minutes.
C. Place the woman in a lateral position.
D. Turn off the continuous epidural. - ANS ✔✔Place the woman in a lateral position.
Rationale
The nurse should immediately turn the woman to a lateral position, place a pillow or wedge
under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and
administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if
it further decreases, the anesthesiologist/healthcare provider should be notified immediately.
A client receiving epidural anesthesia begins to experience nausea and becomes pale and
clammy. What intervention should the nurse implement first?
A. Raise the foot of the bed.
B. Assess for vaginal bleeding.
C. Evaluate the fetal heart rate.
,D. Take the client's blood pressure. - ANS ✔✔Raise the foot of the bed.
Rationale
These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia.
Raising the foot of the bed will increase venous return and provide blood to the vital areas.
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?
A. Discontinue the oxytocin (Pitocin) infusion.
B. Place the client in a semi-Fowler's position.
C. Inform the healthcare provider.
D. Apply firm pressure to sacral area. - ANS ✔✔Apply firm pressure to sacral area.
Rationale
The discomfort of "back labor" can be minimized by the application of firm pressure to the
sacral area.
In developing a teaching plan for expectant parents, the nurse plans to include information
about when the parents can expect the infant's fontanels to close. The nurse bases the
explanation on knowledge that for the normal newborn, the
A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
,D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second
month. - ANS ✔✔anterior fontanel closes at 12 to 18 months and the posterior by the end of
the second month.
Rationale
In the normal infant the anterior fontanel closes at 12 to 18 months of age and the posterior
fontanel by the end of the second month .
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In
which sequence should the nurse implement these nursing actions? (Place the first action on
top and last action on the bottom.)
1.
Reposition the client.
2.
Provide oxygen via face mask.
3.
Increase IV fluid.
4.
Call the healthcare provider. - ANS ✔✔1.
Reposition the client.
2.
Increase IV fluid.
3.
Provide oxygen via face mask.
4.
Call the healthcare provider.
, Rationale
To stabilize the fetus, intrauterine resuscitation becomes the first priority. In order to enhance
the fetal blood supply, the laboring client should be repositioned to displace the gravid uterus
and improve fetal perfusion. Secondly, the IV fluids should be increased to expand the maternal
circulating blood volume. The next step to optimize oxygenation of the circulatory blood volume
is to apply oxygen via face to the mother. Finally, the last step is to notify the primary healthcare
provider for additional interventions to resolve the fetal stress.
When evaluating maternal bonding, which of the following maternal behaviors exhibited by the
client would the nurse most likely expect to see when a new mother receives her infant for the
first time?
A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
B. Her arms and hands receive the infant and she then traces the infant's profile with her
fingertips.
C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
D. She eagerly reaches for the infant and then holds the infant close to her own body. - ANS
✔✔Her arms and hands receive the infant and she then traces the infant's profile with her
fingertips.
Rationale
Attachment/bonding theory indicates that most mothers will demonstrate behaviors such as
tracing the infant's profile with her fingertips during the initial visit with the newborn, which
may be at delivery or later.
