HESI Summer MC options offered + rationales
A 23-year-old client who is receiving Medicaid benefits is pregnant with
her first child. Based on knowledge of the statistics related to infant
mortality, which plan should the nurse implement with this client?
Refer the client to a social worker to arrange for home care.
Recommend perinatal care from an obstetrician, not a nurse-midwife.
Teach the client why keeping prenatal care appointments is important.
Advise the client that neonatal intensive care may be needed. Ans✓✓✓
Teach the client why keeping prenatal care appointments is important.
Rationale
Regular prenatal visits should begin early in pregnancy to monitor health
of the mother and development of the fetus.
A 24-hour-old newborn has a pink papular rash with vesicles
superimposed on the thorax, back, and abdomen. What action should the
nurse implement?
Notify the healthcare provider.
Move the newborn to an isolation nursery.
Document the finding in the infant's record.
Obtain a culture of the vesicles. Ans✓✓✓ document the finding in the
infant's record
,Rationale
Erythema toxicum (or erythema neonatorum) is a newborn rash that is
commonly referred to as "flea bites," but is a normal finding that is
documented in the infant's record, and requires no further action.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-
weeks gestation in preterm labor. She is given 3 doses of terbutaline
sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions.
Which assessment finding would provide the nurse the earliest
indication that the client is experiencing primary side effects of
terbutaline sulfate?
A. Drowsiness and bradycardia.
B. Depressed reflexes and increased respirations.
C. Tachycardia and a feeling of nervousness.
D. A flushed, warm feeling and a dry mouth. Ans✓✓✓ Tachycardia
and a feeling of nervousness.
Rationale
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug which
stimulates beta-adrenergic receptors in the uterine muscle to stop
contractions. The beta-adrenergic agonist properties of the drug may
cause tachycardia, increased cardiac output, restlessness, headache, and
a feeling of "nervousness".
,A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started
on IV magnesium sulfate after being diagnosed with severe
preeclampsia. After determining the serum magnesium level to be 15
mEq/L, the nurse should expect which of the following manifestations in
the client?
ECG changes.
Loss of reflexes.
Respiratory distress.
Cardiac arrest. Ans✓✓✓ Respiratory distress.
Rationale
The therapeutic level of magnesium sulfate is 4 to 7 mEq/L. ECG
changes occur at 5 to 10 mEq/L. Loss of reflexes is unavoidable at 8 to
12 mEq/L. At 15 mEq/L, the client may experience respiratory distress.
At 25 mEq/L, cardiac arrest may occur.
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-
weeks gestation in preterm labor. She is given a dose of terbutaline
sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the
highest priority for the nurse to monitor during the administration of this
drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
, Deep tendon reflexes. Ans✓✓✓ Maternal and fetal heart rates.
Rationale
Monitoring maternal and fetal heart rates is most important when
terbutaline is being administered becauseTerbutaline acts as a
sympathomimetic agent that stimulates both beta 1 receptors (causing
tachycardia, a side effect of the drug) and beta 2 receptors (causing
uterine relaxation, a desired effect of the drug).
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-
weeks gestation in preterm labor. She is started on an IV solution of
terbutaline (Brethine). Which assessment is the highest priority for the
nurse to monitor during the administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes. Ans✓✓✓ Maternal and fetal heart rates.
Rationale
Terbutaline has effects on receptors. It acts as a sympathomimetic agent
stimulating beta 1 receptors which cause tachycardia as a side effect and
that is a reason why monitoring maternal and fetal heart rates is most
important when terbutaline is being administered. It also affects beta 2
receptors which relaxes the uterus and that is the reason for its
administration.
A 23-year-old client who is receiving Medicaid benefits is pregnant with
her first child. Based on knowledge of the statistics related to infant
mortality, which plan should the nurse implement with this client?
Refer the client to a social worker to arrange for home care.
Recommend perinatal care from an obstetrician, not a nurse-midwife.
Teach the client why keeping prenatal care appointments is important.
Advise the client that neonatal intensive care may be needed. Ans✓✓✓
Teach the client why keeping prenatal care appointments is important.
Rationale
Regular prenatal visits should begin early in pregnancy to monitor health
of the mother and development of the fetus.
A 24-hour-old newborn has a pink papular rash with vesicles
superimposed on the thorax, back, and abdomen. What action should the
nurse implement?
Notify the healthcare provider.
Move the newborn to an isolation nursery.
Document the finding in the infant's record.
Obtain a culture of the vesicles. Ans✓✓✓ document the finding in the
infant's record
,Rationale
Erythema toxicum (or erythema neonatorum) is a newborn rash that is
commonly referred to as "flea bites," but is a normal finding that is
documented in the infant's record, and requires no further action.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-
weeks gestation in preterm labor. She is given 3 doses of terbutaline
sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions.
Which assessment finding would provide the nurse the earliest
indication that the client is experiencing primary side effects of
terbutaline sulfate?
A. Drowsiness and bradycardia.
B. Depressed reflexes and increased respirations.
C. Tachycardia and a feeling of nervousness.
D. A flushed, warm feeling and a dry mouth. Ans✓✓✓ Tachycardia
and a feeling of nervousness.
Rationale
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug which
stimulates beta-adrenergic receptors in the uterine muscle to stop
contractions. The beta-adrenergic agonist properties of the drug may
cause tachycardia, increased cardiac output, restlessness, headache, and
a feeling of "nervousness".
,A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started
on IV magnesium sulfate after being diagnosed with severe
preeclampsia. After determining the serum magnesium level to be 15
mEq/L, the nurse should expect which of the following manifestations in
the client?
ECG changes.
Loss of reflexes.
Respiratory distress.
Cardiac arrest. Ans✓✓✓ Respiratory distress.
Rationale
The therapeutic level of magnesium sulfate is 4 to 7 mEq/L. ECG
changes occur at 5 to 10 mEq/L. Loss of reflexes is unavoidable at 8 to
12 mEq/L. At 15 mEq/L, the client may experience respiratory distress.
At 25 mEq/L, cardiac arrest may occur.
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-
weeks gestation in preterm labor. She is given a dose of terbutaline
sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the
highest priority for the nurse to monitor during the administration of this
drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
, Deep tendon reflexes. Ans✓✓✓ Maternal and fetal heart rates.
Rationale
Monitoring maternal and fetal heart rates is most important when
terbutaline is being administered becauseTerbutaline acts as a
sympathomimetic agent that stimulates both beta 1 receptors (causing
tachycardia, a side effect of the drug) and beta 2 receptors (causing
uterine relaxation, a desired effect of the drug).
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-
weeks gestation in preterm labor. She is started on an IV solution of
terbutaline (Brethine). Which assessment is the highest priority for the
nurse to monitor during the administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes. Ans✓✓✓ Maternal and fetal heart rates.
Rationale
Terbutaline has effects on receptors. It acts as a sympathomimetic agent
stimulating beta 1 receptors which cause tachycardia as a side effect and
that is a reason why monitoring maternal and fetal heart rates is most
important when terbutaline is being administered. It also affects beta 2
receptors which relaxes the uterus and that is the reason for its
administration.
