HESI NCLEX-RN COMPREHENSIVE
[MATERNITY] EXAMINATION
A 25-year-old client has a positive pregnancy test. One year ago she had a
spontaneous abortion at 3 months of gestation. Which is the correct description of
this client that should be documented in the medical record?
A. Gravida 1, para 0
B. Gravida 1, para 1
C. Gravida 2, para 0
D. Gravida 2, para 1 - ANSWER-C
Rationale:
This is the client's second pregnancy or second gravid event, so option C is correct.
The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12
weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20
weeks of gestation or beyond. Option A does not take into account the current
pregnancy, nor does option B, which also counts the miscarriage as a "para," an
incorrect recording. Although option D is correct concerning gravidity, para 1 is
incorrect.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of
gestation in preterm labor. She is given three doses of terbutaline sulfate
(Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the
primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
,B. Depressed reflexes and increased respirations
C. Tachycardia and a feeling of nervousness
D. A flushed warm feeling and dry mouth - ANSWER-C
Rationale:
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, 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. Option A is not a side effect.
Options B and D are side effects of magnesium sulfate.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction will
aid in the prevention of pooling of blood in the lower extremities?
A.Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
D. Avoid constrictive clothing. - ANSWER-C
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will relieve pressure on the
pelvic veins and increase venous return. Option A would increase venous return
from varicose veins in the lower extremities but would be of little help with
swelling. Option B might be helpful with generalized edema but is not specific for
edematous lower extremities. Option D does not address venous return, and there
is no indication in the question that constrictive clothing is a problem.
,A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor.
Contractions are firm and occurring every 5 minutes, with a 30- to 40-second
duration. The fetal heart rate increases with each contraction and returns to
baseline after the contraction. Which action should the nurse implement?
A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin (Pitocin) infusion. - ANSWER-D
Rationale:
The goal of labor augmentation is to produce firm contractions that occur every 2
to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal
stress. FHR accelerations are a normal response to contractions, so the oxytocin
(Pitocin) infusion should be increased per protocol to stimulate the frequency and
intensity of contractions. Options A and C are indicated for fetal stress. A sterile
vaginal examination places the client at risk for infection and should be performed
when the client exhibits signs of progressing labor, which is not indicated at this
time.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy
is prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the 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. - ANSWER-A
, 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. Option B is less
painful but does not facilitate complete emptying of the breast tissue. Option C will
not relieve the engorgement on the affected side. Option D will not decrease
antibiotic effects on the infant.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has
just experienced a small amount of vaginal bleeding, which she describes as bright
red. The bleeding has subsided. She further states that she is not experiencing any
uterine contractions or abdominal pain. What instruction should the nurse provide?
A. Come to the clinic today for an ultrasound.
B. Go immediately to the emergency department.
C. Lie on your left side for about 1 hour and see if the bleeding stops.
D. Take a urine specimen to the laboratory to see if you have a urinary tract
infection (UTI). - ANSWER-A
Rationale:
Third-trimester painless bleeding is characteristic of a placenta previa. Bright red
bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed
by transabdominal ultrasound. Bleeding that has a sudden onset and is
accompanied by intense uterine pain indicates abruptio placenta, which is life
threatening to the mother and fetus. If those symptoms were described, option B
would be appropriate. Option C does not address the cause of the symptoms. The
client is not describing symptoms of a UTI.
[MATERNITY] EXAMINATION
A 25-year-old client has a positive pregnancy test. One year ago she had a
spontaneous abortion at 3 months of gestation. Which is the correct description of
this client that should be documented in the medical record?
A. Gravida 1, para 0
B. Gravida 1, para 1
C. Gravida 2, para 0
D. Gravida 2, para 1 - ANSWER-C
Rationale:
This is the client's second pregnancy or second gravid event, so option C is correct.
The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12
weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20
weeks of gestation or beyond. Option A does not take into account the current
pregnancy, nor does option B, which also counts the miscarriage as a "para," an
incorrect recording. Although option D is correct concerning gravidity, para 1 is
incorrect.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of
gestation in preterm labor. She is given three doses of terbutaline sulfate
(Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the
primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
,B. Depressed reflexes and increased respirations
C. Tachycardia and a feeling of nervousness
D. A flushed warm feeling and dry mouth - ANSWER-C
Rationale:
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, 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. Option A is not a side effect.
Options B and D are side effects of magnesium sulfate.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction will
aid in the prevention of pooling of blood in the lower extremities?
A.Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
D. Avoid constrictive clothing. - ANSWER-C
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will relieve pressure on the
pelvic veins and increase venous return. Option A would increase venous return
from varicose veins in the lower extremities but would be of little help with
swelling. Option B might be helpful with generalized edema but is not specific for
edematous lower extremities. Option D does not address venous return, and there
is no indication in the question that constrictive clothing is a problem.
,A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor.
Contractions are firm and occurring every 5 minutes, with a 30- to 40-second
duration. The fetal heart rate increases with each contraction and returns to
baseline after the contraction. Which action should the nurse implement?
A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin (Pitocin) infusion. - ANSWER-D
Rationale:
The goal of labor augmentation is to produce firm contractions that occur every 2
to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal
stress. FHR accelerations are a normal response to contractions, so the oxytocin
(Pitocin) infusion should be increased per protocol to stimulate the frequency and
intensity of contractions. Options A and C are indicated for fetal stress. A sterile
vaginal examination places the client at risk for infection and should be performed
when the client exhibits signs of progressing labor, which is not indicated at this
time.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy
is prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the 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. - ANSWER-A
, 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. Option B is less
painful but does not facilitate complete emptying of the breast tissue. Option C will
not relieve the engorgement on the affected side. Option D will not decrease
antibiotic effects on the infant.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has
just experienced a small amount of vaginal bleeding, which she describes as bright
red. The bleeding has subsided. She further states that she is not experiencing any
uterine contractions or abdominal pain. What instruction should the nurse provide?
A. Come to the clinic today for an ultrasound.
B. Go immediately to the emergency department.
C. Lie on your left side for about 1 hour and see if the bleeding stops.
D. Take a urine specimen to the laboratory to see if you have a urinary tract
infection (UTI). - ANSWER-A
Rationale:
Third-trimester painless bleeding is characteristic of a placenta previa. Bright red
bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed
by transabdominal ultrasound. Bleeding that has a sudden onset and is
accompanied by intense uterine pain indicates abruptio placenta, which is life
threatening to the mother and fetus. If those symptoms were described, option B
would be appropriate. Option C does not address the cause of the symptoms. The
client is not describing symptoms of a UTI.
