MATERNITY HESI EXAM WITH 350
COMPLETE QUESTIONS AND CORRECT
ANSWERS WITH RATIONALE
QUESTIONA female client who wants to delivery at home asks the nurse to
explain the role of a nurse-midwife in providing obstetric care. What
information should the nurse provide? - answer-The pregnancy should
progress normally and be considered low risk.
Rationale:
A nurse midwife is an advanced practice nurse who is prepared to provide
quality perinatal care for a low-risk obstetric client.
QUESTIONWhat nursing action should be included in the plan of care for a
newborn experiencing symptoms of drug withdrawal ? - answer-Swaddle
the infant snugly and hold tightly.
Rationale:
An infant experiencing drug withdrawal should be swaddled, wrapped
snugly, or placed in a "kangaroo pouch" to reduce self-stimulation
behaviors and protect skin from abrasions that may occur due to muscular
irritability.
QUESTIONThe nurse is teaching a new mother about diet and
breastfeeding. Which instruction is most important to include in the
,teaching plan? - answer-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.
Which finding in the medical history of a post-partum client should the
nurse withhold the administration of a routine standing order for
methylergonovine maleate (Methergine)? - answer-Pregnancy induced
hypertension.
Rationale:
Methergine is used for post-partum bleeding. A client's history of
pregnancy-induced hypertension is a contraindication for Methergine
which causes vasoconstriction and increases blood pressure, so the
routine standing order should be withheld and reported to the healthcare
provider.
QUESTIONA client at 8-months gestation tells the nurse that she knows
her baby listens to her, but her husband thinks she is imagining things.
What information should the nurse provide? - answer-The fetus in utero is
capable of hearing and does respond to the mother's voice.
Rationale:
Fetal hearing and response to sound occurs by 24-weeks gestation, so the
fetus can be soothed by the familiar sound of the mother's voice.
,QUESTIONA primigravida at 12-weeks gestation who just moved to the
United States indicates she has not received any immunizations. Which
immunization(s) should the nurse administer at this time? (Select all that
apply.)
Tetanus.
Rubella.
Diphtheria.
Chickenpox.
Hepatitis B. - answer-Correct selections are (A, C, and E).
Rationale:
Vaccines composed of killed viruses may be administered during
pregnancy. Rubella (B) and chickenpox (D) consist of live or attenuated live
viruses which would be contraindicated during pregnancy due to potential
teratogenicity.
QUESTIONA client at 25-weeks gestation tells the nurse that she dropped
a cooking utensil last week and her baby jumped in response to the noise.
What information should the nurse provide? - answer-The fetus can
respond to sound by 24-weeks gestation.
Rationale:
At 24-weeks gestation, the fetus's ability to hear loud environment sounds
can illicit a startle response.
, QUESTIONA client at 28-weeks gestation experiences blunt abdominal
trauma. Which parameter should the nurse assess first for signs of
internal hemorrhage? - answer-Changes in fetal heart rate patterns.
Rationale:
Hypoperfusion of the fetus may be present before the onset of clinical
signs of maternal compromise or shock in a pregnant woman, so the
external fetal monitor tracings should be assessed first to determine
signs of fetal hypoxia due to internal bleeding in the mother.
QUESTIONThe nurse is discussing the stages of labor with a group of
women in the last month of pregnancy and provides examples of different
positional techniques used during the second stage of labor. Which
position should the nurse address that provides the best advantage of
gravity during delivery? - answer-Squatting.
Rationale:
Squatting helps to align the fetus with the pelvic outlet and allows gravity
to assist in fetal descent and gives the client an adventitious position for
birth.
QUESTIONA multiparous client is bearing down with contractions and
crying out, "The baby is coming!" Which immediate action should the nurse
implement? - answer-Visualize the perineum for bulging.
Rationale:
COMPLETE QUESTIONS AND CORRECT
ANSWERS WITH RATIONALE
QUESTIONA female client who wants to delivery at home asks the nurse to
explain the role of a nurse-midwife in providing obstetric care. What
information should the nurse provide? - answer-The pregnancy should
progress normally and be considered low risk.
Rationale:
A nurse midwife is an advanced practice nurse who is prepared to provide
quality perinatal care for a low-risk obstetric client.
QUESTIONWhat nursing action should be included in the plan of care for a
newborn experiencing symptoms of drug withdrawal ? - answer-Swaddle
the infant snugly and hold tightly.
Rationale:
An infant experiencing drug withdrawal should be swaddled, wrapped
snugly, or placed in a "kangaroo pouch" to reduce self-stimulation
behaviors and protect skin from abrasions that may occur due to muscular
irritability.
QUESTIONThe nurse is teaching a new mother about diet and
breastfeeding. Which instruction is most important to include in the
,teaching plan? - answer-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.
Which finding in the medical history of a post-partum client should the
nurse withhold the administration of a routine standing order for
methylergonovine maleate (Methergine)? - answer-Pregnancy induced
hypertension.
Rationale:
Methergine is used for post-partum bleeding. A client's history of
pregnancy-induced hypertension is a contraindication for Methergine
which causes vasoconstriction and increases blood pressure, so the
routine standing order should be withheld and reported to the healthcare
provider.
QUESTIONA client at 8-months gestation tells the nurse that she knows
her baby listens to her, but her husband thinks she is imagining things.
What information should the nurse provide? - answer-The fetus in utero is
capable of hearing and does respond to the mother's voice.
Rationale:
Fetal hearing and response to sound occurs by 24-weeks gestation, so the
fetus can be soothed by the familiar sound of the mother's voice.
,QUESTIONA primigravida at 12-weeks gestation who just moved to the
United States indicates she has not received any immunizations. Which
immunization(s) should the nurse administer at this time? (Select all that
apply.)
Tetanus.
Rubella.
Diphtheria.
Chickenpox.
Hepatitis B. - answer-Correct selections are (A, C, and E).
Rationale:
Vaccines composed of killed viruses may be administered during
pregnancy. Rubella (B) and chickenpox (D) consist of live or attenuated live
viruses which would be contraindicated during pregnancy due to potential
teratogenicity.
QUESTIONA client at 25-weeks gestation tells the nurse that she dropped
a cooking utensil last week and her baby jumped in response to the noise.
What information should the nurse provide? - answer-The fetus can
respond to sound by 24-weeks gestation.
Rationale:
At 24-weeks gestation, the fetus's ability to hear loud environment sounds
can illicit a startle response.
, QUESTIONA client at 28-weeks gestation experiences blunt abdominal
trauma. Which parameter should the nurse assess first for signs of
internal hemorrhage? - answer-Changes in fetal heart rate patterns.
Rationale:
Hypoperfusion of the fetus may be present before the onset of clinical
signs of maternal compromise or shock in a pregnant woman, so the
external fetal monitor tracings should be assessed first to determine
signs of fetal hypoxia due to internal bleeding in the mother.
QUESTIONThe nurse is discussing the stages of labor with a group of
women in the last month of pregnancy and provides examples of different
positional techniques used during the second stage of labor. Which
position should the nurse address that provides the best advantage of
gravity during delivery? - answer-Squatting.
Rationale:
Squatting helps to align the fetus with the pelvic outlet and allows gravity
to assist in fetal descent and gives the client an adventitious position for
birth.
QUESTIONA multiparous client is bearing down with contractions and
crying out, "The baby is coming!" Which immediate action should the nurse
implement? - answer-Visualize the perineum for bulging.
Rationale:
