Hesi Exam

.Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet: Continue to monitor (normal). 2.20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What warrants further evaluation? Too much weight gain, gestational weight gain should only be approx 10.3 lbs. 3. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"? Active movement and lusty cry. 4.24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say... If your baby’s urine is straw colored , then she is feeding well. 5. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate Inspect perineal and rectal area. 6.Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx? Fluid volume excess. RATIONALE: 3rd spacing. 7.Cesarean - hemorrhage risk assessment? Check for fundal firmness Q15 min. RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery. Q15 min checks stimulate fundus to contract and prevents bleeding. 8.Water broke, umbilical cord is on perineum, what does nurse do? Place pt in trendelenburg. RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up the presenting part as much as possible. 9.Primipara 20 week, schedule u/s, what's the reason for the u/s? To evaluate fetal growth and to determine gestational age. 10Assessing a 3 day old with cephalohematoma. What intervention is highest priority? Examine Q8 hrs for jaundice (look for hyperbilirubinemia). RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown. 11.40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia. What would be a therapeutic response to the injection? Increased HR and decrease in oral secretions. 12.Newborn assessment that indicates a cardiac problem? RR 78/min. RATIONALE: Normal respiratory rate for a newborn is 40 - 60. 13Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give? Give 1.5 tabs. 14.Sore nipples on day 2 of breastfeeding. Assess infants position while feeding. RATIONALE: To make sure baby is latching properly. 15.Rh negative refuses Rhogam after delivery. Rhogam prevents maternal antibody formation for future Rh positive babies. 16.24 hours after birth, cephalohematoma, what intervention Examine jaundice Q8 hours RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown. 17. Patient had twins born to multigravida, 12 hours ago. Nursing Dx? Assess fundal tone and lochia flow. 18. Primigravida, 36 week, admitted, water broke, 2cm dilated, 50% effaced, -2 station, vertex presentation, greenish colored amniotic fluid, contractions Q3-5 min with deceased in FHR after the last 4 contraction peaks. What to do FIRST? 02 via facemask. Terbutaline (Brethine) injections for preterm labor.