HESI PN MATERNITY EXAM QUESTIONS AND ANSWERS WITH RATIONALES 2024

During labor, the fetal heart rate slowly decelerates at the beginning of the contraction and returns to baseline at the end of the contraction. What action should the nurse take? a. Turn the mother to her left side. b. Administer oxygen to the mother via face mask. c. Notify the health care provider regarding the findings. d. Continue to monitor the progress of the client’s labor. D) Continue to monitor the progress of the client’s labor. Rationale: Early decelerations during labor are frequently caused by head compression within the uterus, and no nursing intervention is required except to monitor the mother’s progress during labor. Which maternal behavior is the practical nurse (PN) most likely to see when a new mother receives her infant for the first time? a. She eagerly undresses the infant and examines the infant completely. b. She receives the infant and touches the infant’s face with her fingertips. c. She reaches and cuddles the infant to her own body. d. She reaches but hesitates for the nurse’s encouragement. B) She receives the infant and touches the infant’s face with her fingertips. Rationale: Attachment/bonding theory indicates that most mothers will touch the infant’s face during the first visit with the newborn. A new father asks the practical nurse (PN) why ointment is instilled into the eyes of his newborn infant. Which infection should the PN identify when describing the purpose of this treatment? a. Herpes b. Staphylococcus c. Gonorrhea d. Syphilis C) Gonorrhea Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The nurse is taking the temperature of a client who is 6 hours postpartum. The nurse notes that the client’s temperature is 38° C (100.4° F). Which intervention should the nurse implement? a. Encourage fluids to increase hydration. b. Recheck the temperature in 15 minutes. c. Place an ice pack on the client’s forehead. d. Obtain a prescription for acetaminophen. A) Encourage fluids to increase hydration. Rationale: It is normal for the postpartum client to have a temperature up to 38° C (100.4° F) because of dehydration caused by labor. The most appropriate intervention is to encourage fluids to rehydrate the patient. *Above 38° C (100.4° F) is critical A newborn infant is breathing satisfactorily but appears dusky. What action should the practical nurse (PN) take first? a. Notify the pediatrician immediately. b. Suction the infant’s nares and then the oral cavity. c. Check the infant’s oxygen saturation rate. d. Position the infant on the right side. C) Check the infant’s oxygen saturation rate. Rationale: The PN should first obtain measurable objective data; an oxygen saturation rate provides such information. The pediatrician should be notified if the oxygen saturation rate is below 90%. The practical nurse (PN) caring for a laboring client encourages her to void at least every 2 hours and records each time the client empties her bladder. What is the rationale for implementing this nursing intervention? a. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part b. An overdistended bladder could be traumatized during labor and could prolong the progress of labor. c. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. d. Frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection. B) An overdistended bladder could be traumatized during labor and could prolong the progress of labor. Rationale: A full bladder can impair the efficiency of the uterine contractions and impede descent of the fetus during labor. Also, because of the close proximity of the bladder to the uterus, the bladder can be traumatized by the descent of the fetus. During a prenatal visit, the practical nurse (PN) discusses with a client the effects that smoking has on the fetus. The nurse realizes the teaching is effective if the client identifies which possible effect on the fetus? a. Lower Apgar score recorded at delivery. b. Lower initial weight documented at birth. c. Higher oxygen used to stimulate breathing. d. Higher prevalence of congenital anomalies. B) Lower initial weight documented at birth. Rationale: Smoking is associated with low-birth-weight infants. Following a vaginal delivery, a postpartum client complains of severe cramping after breastfeeding her newborn. Which explanation describes the most likely reason for the client’s pain? a. A retained placenta b. Problems with the process of involution c. The release of oxytocin hormone d. A possible ileus C) The release of oxytocin hormone Rationale: During breastfeeding, oxytocin is released and will cause uterine contractions and cramping. A female who thinks she could be pregnant calls her neighbor, a practical nurse (PN), to ask when she should use a home pregnancy test to diagnose pregnancy. Which response is best? a. “A home pregnancy test can be used right after your first missed period.” b. “These tests are most accurate after you have missed your second period.” c. “Home pregnancy tests often give false-positives and should not be trusted.” d. “The test can provide accurate information when used right after ovulation.” A) “A home pregnancy test can be used right after your first missed period.” Rationale: Home urine tests are based on the chemical detection of human chorionic gonadotrophin, which begins to increase 6 to 8 days after conception and is best detected at 2 weeks’ gestation or immediately after the first missed period. A client who is 8 hours postpartum uses the call system and tells the nurse “I think I’m bleeding a lot.” The nurse notes a large amount of rubra flow on the sanitary pad and linen protector. What is the nurse’s first action? a. Take the client’s vital signs. b. Notify the health care provider. c. Massage the client’s fundus until it firms. d. Change the sanitary pad and the linen protector. C) Massage the client’s fundus until it firms. Rationale: The initial action for postpartum hemorrhage is to massage the fundus. Taking the vital signs and notifying the health care provider may be necessary, but massaging the fundus is the primary action. The nurse is assisting with data collection for a client who is in her 10th week of pregnancy. Which finding should be reported immediately to the health care provider? a. The client’s rubella titer is less than 1:10. b. The client’s hematocrit value is measured at 34%. c. The client states “I’m not really sure I want to have a baby.” d. The client states she will not be able to visit the health care provider every 2 weeks. A) The client’s rubella titer is less than 1:10. Rationale: The client’s rubella titer indicates she is not immune to rubella, making the fetus at risk for serious birth defects. A rubella titer over 1:10 indicates immunity. During the first trimester, the hematocrit should be over 33%, so 34% is adequate for this client. Ambivalence about the pregnancy is common in the first trimester. The client will need to visit the health care provider every 4 weeks, not every 2 weeks. A new mother asks the practical nurse (PN), “How do I know that my daughter is getting enough breast milk?” Which explanation best supports that the mother has adequate milk supply? a. “Weigh the baby daily, and if she is gaining weight, she is getting enough to eat.” b. “Your milk is sufficient if the baby is voiding pale, straw-colored urine 6 to 10 times a day.” c. “Offer the baby extra bottle milk after her feeding, and see if she is still hungry.” d. “If you’re concerned, you might consider bottle feeding so that you can monitor her intake.” B) “Your milk is sufficient if the baby is voiding pale, straw-colored urine 6 to 10 times a day.” Rationale: The urine will be dilute (straw-colored) and frequent (greater than six to ten times/day) if the infant is adequately hydrated. A new mother has delivered her first baby vaginally and says to the practical nurse (PN), I saw the baby in the recovery room. The baby sure has a funny- looking head. Which response by the PN is best? a. This is not an unusual-shaped head, especially for a first baby. b. It may look odd, but newborn babies are often born with heads like that. c. That is normal. The head will return to a round shape within 7 to 10 days. d. Your pelvis was too small, so the head had to adjust to the birth canal. C) That is normal. The head will return to a round shape within 7 to 10 days. Rationale: Reassure the mother that this shape is normal in the newborn and then provide information regarding the return to a normal shape of the molded neonate’s head after a vaginal delivery. The nurse has reinforced education for a client who is 11 weeks pregnant and has had no pregnancy complications. Which client comment indicates adequate understanding of the instructions? a. “I can exercise as long as I do not start sweating.” b. “I will reduce my fluid intake if I take a trip by airplane.” c. “I can expect my nausea to be reduced in the next few weeks.” d. “As long as I do not have more than 1 drink a day, I can continue to take alcohol.” C) “I can expect my nausea to be reduced in the next few weeks.” Rationale: Pregnancy-related nausea usually resolves by the 13th week. If the client travels via airplane, the client should take additional fluids to prevent deep vein thrombosis. The healthy client can exercise as long as she is able to converse easily while exercising. No level of alcohol is considered safe while pregnant. The nurse is assisting with data collection on a woman in her first trimester of pregnancy. Which findings should be reported to the health care provider immediately? (Select all that apply.) a. Cramping with bright red spotting b. Increased urination c. Lack of breast tenderness d. Increased amount of vaginal discharge e. Right-sided flank pain A) Cramping with bright red spotting C) Lack of breast tenderness E) Right-sided flank pain Rationale: Cramping with bright red spotting and lack of breast tenderness could indicate that miscarriage is occurring. Option E could be an indication of an ectopic pregnancy, which could be fatal if not treated before rupture. Options B and D are common occurrences during the first trimester of pregnancy. The nurse is providing care to a mother who has experienced a fetal demise in utero at 35 weeks’ gestation. The nurse expects to see which aspects included in the client’s plan of care? ( Select all that apply.) a. Contact the hospital chaplain if the mother prefers. b. Ask about the last fetal movements if not already documented in the medical record. c. Apply the electronic fetal cardiac monitor. d. Ask about plans for labor pain management. e. Ask the parents if they want to hold the baby after birth. A) Contact the hospital chaplain if the mother prefers. B) Ask about the last fetal movements if not already documented in the medical record. D) Ask about plans for labor pain management. E) Ask the parents if they want to hold the baby after birth. Rationale: If the mother prefers, the chaplain can be contacted to provide additional support through this difficult time. The chaplain may baptize the baby, depending on the beliefs of the parents. Determining the last fetal movements can give an approximation of when the demise occurred. If the death occurred 3 weeks ago or longer, the mother is at risk of developing disseminated intravascular coagulation (DIC). Pain management will be important to the mother who has lost a child. Determine the parents’ desire after the birth to facilitate bonding. There is no need to monitor the heart rate of a fetus that has died in utero. A mother who is positive for the HIV virus delivers a 7-pound boy. Which intervention should the practical nurse initiate to prevent transfer of the virus to the infant? a. Provide a particulate filter mask for the mother to wear. b. Prevent breastfeeding but encourage rooming-in. c. Remind the mother to wash hands carefully after bowel movements. d. Teach the mother to glove during diaper changes. B) Prevent breastfeeding but encourage rooming-in. Rationale: Rooming-in should be allowed, but transmission of the mother’s body fluids (breast milk) should be prevented. Standard precautions should be instituted. The practical nurse (PN) is reinforcing teaching to a new mother about diet and breastfeeding. Which instruction is most important to include? a. Avoid alcohol because it is excreted in breast milk. b. Eat a high-fiber diet to help prevent constipation. c. Increase caloric intake by approximately 500 calories/day. d. Increase fluid intake to 3 quarts/day. A) Avoid alcohol because it is excreted in breast milk. Rationale: Alcohol should be avoided while breastfeeding because when consumed by the mother, it is excreted in breast milk and may cause a variety of problems for the infant. The nurse is reinforcing instructions on newborn care for expectant parents. Which instruction is correct for the nurse to include concerning the newborn infant born at term? a. Milia are red marks made by forceps and will disappear within 7 to 10 days. b. Meconium is the first stool and is firm, and usually yellow gold in color. c. Vernix is a white cheesy substance, predominately seen in skin folds. d. Pseudostrabismus found in newborns is treated by minor surgery. C) Vernix is a white cheesy substance, predominately seen in skin folds. Rationale: Vernix, found in skin folds, is a common characteristic of term infants. Milia are white pinpoint spots usually found over the nose and chin, caused by sebaceous glands blockages. Meconium is the first stool, but it is tarry black, not golden yellow. Pseudostrabismus (crossed eyes) is normal at birth and does not require surgery. As part of the preoperative plan of care for a client who is scheduled for a repeat cesarean section, the practical nurse (PN) plans to administer the nonparticulate antacid sodium citrate by mouth. What is the purpose of administering this drug preoperatively? a. Prevent postoperative nausea and vomiting. b. Raise the gastric pH to above 2.5. c. Improve gastric motility. d. Decrease the risk of aspiration. B) Raise the gastric pH to above 2.5. Rationale: Sodium citrate is prescribed to increase the pH of gastric secretions and make them more alkaline so that if the client should vomit and aspirate, the chance of pneumonitis occurring is decreased. The nurse is assisting the health care provider who will be performing an amniocentesis on a client who is 37 weeks pregnant. Which is the priority action for the nurse to take prior to the procedure? a. Give the client at least 2000 mL fluid orally before the procedure. b. Turn the client to the left lateral position before the procedure. c. Inform the client to expect contractions after the procedure. d. Instruct the client to empty her bladder prior to the procedure. D) Instruct the client to empty her bladder prior to the procedure. Rationale: The client who is in late pregnancy should empty her bladder before the procedure to prevent injury to the bladder. It is not necessary to give the client fluids prior to the procedure, or to turn the client to the left lateral position. It is not normal to experience contractions after this procedure, if these happen, the health care provider should be notified. A client at 38 weeks’ gestation calls the antepartal clinic stating she just experienced a small amount of bright red vaginal bleeding that has subsided. She denies uterine contractions or abdominal pain. What information should the practical nurse (PN) provide? a. Come to the clinic today to see the provider. b. You are likely experiencing false labor. c. Lie on your left side for about 1 hour and see if the bleeding stops. d. Tomorrow come to the lab to see if you have a urinary tract infection. A) Come to the clinic today to see the provider. Rationale: The PN should instruct the client to come in to see the provider. Third-trimester painless bleeding is characteristic of a "placenta previa". Bright red bleeding may be intermittent, occur in gushes, or be continuous. A 25-year-old client has a positive pregnancy test. One year earlier she had a spontaneous abortion at 3 months’ gestation. What is the description that the practical nurse (PN) should use to document gravida and parity in this client’s medical record? a. Gravida 1, para 0 b. Gravida 1, para 1 c. Gravida 2, para 0 d. Gravida 2, para 1 C) Gravida 2 , para 0 Rationale: This is the client’s second pregnancy or second “gravid” event, the spontaneous abortion occurred at 3 months’ gestation (12 weeks), so she is a para 0. Parity when delivery occurs at 20 weeks’ gestation or beyond. Gravida: The number of times a woman has been pregnant, current pregnancy included Para: The number of viable births (multiples pregnancies count as one birth). G: gravida (number of pregnancies) T: term births or pregnancies delivered between 38 and 42 weeks of gestation P: preterm births (between 20th and 38th week of gestation) A: abortions L: living children Twenty-four hours after a full-term newborn is admitted to the newborn nursery, the practical nurse (PN) observes a localized swelling on the right side of the head of the newborn that does not cross the suture line. How does the nurse document this finding? a. A cephalohematoma b. A subarachnoid hematoma c. Molding d. A subdural hematoma A) A cephalohematoma Rationale: Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. "localized swelling on side of head of newborn that does not cross suture line" The nurse is assisting with data collection on a client who is in her last trimester of pregnancy. Which findings should the nurse report urgently to the health care provider? (Select all that apply.) a. Increased heartburn that is not relieved with doses of antacids b. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit c. Shoes and rings which are too tight because of peripheral edema in extremities d. Decrease in ability for the client to sleep for more than 2 hours at a time e. Headaches that have been lingering for a week behind the client’s eyes A) Increased heartburn that is not relieved with doses of antacids E) Headaches that have been lingering for a week behind the client’s eyes Rationale: Intractable indigestion and lingering headaches are not unusual during pregnancy, but can be symptoms of preeclampsia and should be reported to the health care provider. The fetal heart rate normally ranges between 120 and 160. Peripheral edema and difficulty sleeping are common during pregnancy and do not warrant immediate notification of the health care provider. A client who is in labor with her 3rd child tells the nurse, “I have to push.” The health care provider had performed a vaginal examination on the client an hour ago and determined the client was 5 cm dilated, 50% effaced. What should be the nurse’s next action? a. Encourage the client to push when she has a contraction. b. Inform the mother she is not dilated enough to begin pushing. c. Contact the client’s health care provider to assess the client’s cervix. d. Instruct the client on ways to relax, and allow her privacy while she relaxes. c. Contact the client’s health care provider to assess the client’s cervix. Rationale: The nurse’s next action should be to contact the health care provider to assess the client’s cervix. Clients who have had more than one delivery can progress through labor quickly. The client should not push when she has a contraction until her cervix has been assessed. The nurse should not inform the client she is not dilated enough until her cervix has been assessed. The client should not be left alone to relax, as delivery is likely imminent. The practical nurse (PN) is assessing a client at 20 weeks’ gestation. Which measurement should be compared with the client’s current weight to obtain data about her weight gain during the entire pregnancy? a. Usual pre-pregnancy weight b. Weight at the first prenatal visit c. Previous pregnancy weight gain d. Daily weight gains or losses a. Usual pre-pregnancy weight Rationale: Comparing the client’s current weight with her pre-pregnancy weight allows for a calculation of total weight gain. During a routine prenatal visit, a female at 38 weeks’ gestation tells the practical nurse (PN) that both her cousin and her cousin’s 1-year-old daughter have phenylketonuria (PKU). The client is concerned that her unborn child may also have PKU and become mentally retarded. Which information should the PN provide? a. An infant with PKU is treated with thyroid medication. b. PKU screening is performed after the newborn ingests milk. c. Genetic testing of the client can identify PKU in the infant. d. The fetus’s risk for PKU is only slightly higher than usual. B) PKU screening is performed after the newborn ingests milk. Rationale: PKU is an inborn error of metabolism resulting in an elevated serum amino acid, phenylalanine, which causes mental retardation; therefore, it’s important to PKU screening after the newborn has ingested breast milk or formula milk protein. The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dL. Based on this finding, which intervention should the practical nurse (PN) implement? a. Provide phototherapy for 30 minutes q8h. b. Feed the newborn with sterile water hourly. c. Encourage the mother to breastfeed frequently. d. Assess the newborn’s blood glucose level. C) Encourage the mother to breastfeed frequently. Rationale: Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin. The normal total bilirubin level is 6 to 12 mg/dL after day 1 of life. The infant should be monitored to prevent further complications. The practical nurse (PN) is caring for a client who has had a normal vaginal delivery. The first 4 hours after delivery, the nurse palpates the uterine fundus and bladder every hour. What is the primary reason for implementing this nursing intervention? a. A full bladder after delivery is an indicator to ambulate the client in order to prevent phlebothrombosis. b. An overdistended bladder could inhibit uterine contraction and predispose to postpartum bleeding. c. Urine specimens for glucose and protein must be obtained at intervals to monitor for preeclampsia states. d. A firm fundus will promote frequent voiding and minimizes the need for urinary catheterization. B) An overdistended bladder could inhibit uterine contraction and predispose to postpartum bleeding. Rationale: A distended, full bladder can impair the efficiency of uterine contraction, which will allow uterine sinuses to bleed and result in the fundus becoming displaced and boggy in consistency. Which parental behavior is a warning to the practical nurse that there may be negative bonding between parents and a newborn infant? a. Parents frequently touch the infant and call the infant by name. b. Parents hold the infant away from the body to show the infant’s face. c. Parents frequently leave the newborn infant wrapped in blankets. d. Parents give immediate attention to infant’s hunger and wet diapers. C) Parents frequently leave the newborn infant wrapped in blankets. Rationale: Attachment/bonding theory indicates that parents have an extreme interest in visualizing every part of the newborn in a head to toe examination and exploration process. A client comes to the OB clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the practical nurse (PN), I’m having second thoughts about wanting to have this baby. Which response is best for the PN to make? a. It’s normal to feel ambivalent about a pregnancy when you are not feeling well. b. I think you should discuss these feelings with your health care provider. c. How does the father of your child feel about you having this baby? d. Tell me about these second thoughts you are having about this pregnancy. D) Tell me about these second thoughts you are having about this pregnancy. Rationale: Although ambivalence is normal during the first trimester; however, it’s best to ask the client to verbalize her feelings to clarify and determine any underlying concerns. Ambivalence: the state of having mixed feelings or contradictory ideas about something or someone. "the law's ambivalence about the importance of a victim's identity" A pregnant client is being discharged after presenting to the labor and delivery unit in false labor. The nurse explains to the client the signs of true labor. Which statement made by the client indicates that further teaching is required? a. My contractions will not go away if I walk around. b. My contractions will get stronger and closer together. c. My contractions may feel like really bad menstrual cramps. d. My contractions will be irregular and felt in my abdomen. D) My contractions will be irregular and felt in my abdomen. Rationale: False labor contractions are irregular, do not progress, and are usually felt in the abdomen or groin. Twenty four hours after forceps-assisted birth, the nurse assesses a full-term infant who has developed localized swelling on the right side of the head. The swelling occurs between the periosteum and skull and does not cross over the suture line. What action is most appropriate for the nurse to take? a. Document the findings as cephalohematoma. b. Reassure the parents this is called molding. c. Ask the health care provider for a prescription for an ice pack to reduce swelling. d. Notify the health care provider that this child likely is experiencing a subdural hematoma. A) Document the findings as cephalohematoma. Rationale: Cephalohematoma is a slight abnormal variation of the newborn, common after a forceps delivery. An ice pack will not have any effect on this condition. There is no evidence the newborn is experiencing a subdural hematoma. A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. What instruction should the practical nurse (PN) reinforce to this client? a. Breastfeed the infant, ensuring that both breasts are completely emptied. b. Pump the infected breast to avoid pain of the infant latching onto the infected breast. c. Breastfeed on the unaffected breast only until the mastitis subsides. d. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. A) Breastfeed the infant, ensuring that both breasts are completely emptied. Rationale: Mastitis (caused by plugged milk ducts) is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. The practical nurse is teaching a primigravida about breastfeeding. Which finding requires follow-up? a. The client wears push-up bras because of small breasts. b. The client plans to enroll in an exercise class to regain her figure. c. The client drinks one or two beers each evening to relax. d. The client uses warm water, but no soap, to wash her nipples. C) The client drinks one or two beers each evening to relax. Rationale: Alcohol of all kinds should be avoided while breastfeeding, because it can be transferred through the breast milk to the infant and can cause CNS depression in the infant. The practical nurse (PN) calls for help and gives two breaths to a newborn who is not breathing. Which area on the image would the PN check for the newborn’s pulse? a. A b. B c. C d. D B) B Rationale: The brachial pulse is used to determine the presence of a pulse in the infant during cardiopulmonary resuscitation. During labor, a client is experiencing a fetal heart rate of 68, which lasts longer than 45 seconds. Which is the nurse’s first action? a. Turn the client to her left side. b. Administer additional oral fluids. c. Assess the client’s blood glucose level. d. Assess the client’s vital signs and oxygen saturation. A) Turn the client to her left side. Rationale: The client should be turned to her left side immediately, as turning her may take the weight of the uterus and reduce the pressure the heavy uterus is placing on the client’s blood vessels. Administering oral fluids may be contraindicated, because a Caesarian section may be required if the fetal bradycardia persists. The client’s symptoms do not correlate with a blood sugar disorder. Assessing the client’s vital signs and oxygen saturation is necessary, but it is not a priority action. A client who is 40 weeks into pregnancy is having a vaginal examination at the clinic when the nurse notes a sudden gush of yellowish, clear fluid from the vaginal area. What should be the nurse’s first action? a. Measure the fetal heart rate. b. Monitor for uterine contractions. c. Note the color and odor of the fluid. d. Apply a dry pad under the client for her comfort. A) Measure the fetal heart rate. Rationale: When the amniotic sac ruptures, there is a risk that the umbilical cord could prolapse, causing fetal bradycardia and decreased blood supply to the fetus. The nurse should measure the fetal heart rate immediately when the amniotic sac ruptures. If the cord has prolapsed, the fetus needs to be delivered immediately. It is important to note the color and odor of the fluid for signs of infection and to assess for uterine contractions; however, the priority is assessing for a prolapsed cord by assessing the fetal heart rate. Placing a dry pad under the client is not a priority action. A client who is in active labor requests pain relief measures and prefers epidural anesthesia. Which action should the nurse take when caring for this client? (Select all that apply.) a. Restrict oral and intravenous fluids for 2 hours prior to the epidural. b. Explain to the client she will be having a metal taste in her mouth soon. c. Monitor the client’s vital signs and immediately report hypotension. d. Assist the client into a prone position while the epidural is administered. C) Monitor the client’s vital signs and immediately report hypotension. Rationale: Hypotension is a common adverse effect of epidural anesthesia. Intravenous fluids are infused to provide 500 to 1000 mL additional fluids prior to the procedure; fluids are not restricted. A metallic taste in the mouth indicates the medication has entered the bloodstream. Immediately notify the health care provider if this occurs. Epidural anesthesia is administered while the client is in the sitting position. The practical nurse (PN) is caring for a gravida 4, para 3, with a history of rheumatic heart disease, admitted to the antepartum unit in preterm labor at 32 weeks’ gestation. Which assessment findings indicate the onset of cardiac failure requiring immediate intervention? a. Edema, adventitious lung sounds, and tachycardia b. Increased urinary output and irregular heart rate c. Shortness of breath, bradycardia, and hypertension d. Regular heart rate and hypertension A) Edema, adventitious lung sounds, and tachycardia Rationale: Edema, adventitious lung sounds, and an irregular pulse indicate cardiac decompensation and require immediate intervention.