HESI Maternity- Practice Questions
Which finding(s) is (are) most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (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 that 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. Chronic headache that has been lingering for a week behind the client's eyes
(A and E) are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. (B, C, and D) are all normal signs during the last trimester of pregnancy.
On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth (EDB)? A. November 22 B. November 8 C. December 22 D. October 22
(A) correctly applies Nägele's rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15 + 7 = 22). (B, C, and D) are not calculated correctly.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate? 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 six to ten times a day." C. "Offer the baby extra bottled milk after her feeding and see if she still seems hungry." D. "If you're concerned, you might consider bottle feeding so that you can monitor intake."
B) The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) (B), if the infant is adequately hydrated. Although a weight gain (A) of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately and the suggestion will likely make the mother anxious. (C) causes nipple confusion and diminishes the mother's milk production. (D) does not address the client's question.
The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A. Herpes B. Trichomonas C. Gonorrhea D. Syphilis
C.) 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 (C), and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against (A, B, or D).
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A. Wash the cord frequently with mild soap and water. B. Cover the cord with a sterile dressing. C. Allow the cord to air-dry as much as possible. D. Apply baby lotion after the baby's daily bath.
C.) Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process (C). (A, B, and D) are incorrect because they promote moisture and increase the potential for infection.
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide formula for the infant until he becomes calm, and then offer the breast again.
C.) The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself (C). After such a time out, breastfeeding is often more successful. (A and D) would cause nipple confusion. (B) would only cause the infant to be more resistant, resulting in the mother and infant to become more frustrated.
When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery.
C.) Vernix, found in the folds of the skin, is a characteristic of term infants (C). Milia (A) are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool (B), but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth (D) through the third or fourth month and does not require surgery.
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the nurse implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby. B. Ask the woman to describe why she was unsuccessful with breastfeeding her last child. C. Encourage the woman to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
D) Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery (D). (A and B) might provide interesting data, but gathering this information is not as important as providing support and instructions to the new mother. Although (C) is also true, this response by the nurse might seem judgmental to a new mother.
During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take? A. Encourage her to pant between contractions and blow with contractions. B. Coach her to take a deep cleansing breath and then refocus. C. Instruct her to pant three times and then exhale through pursed lips. D. Have her cup both hands over her nose and mouth while breathing.
D.) Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both her hands over her mouth and nose (D) so that she can rebreathe carbon dioxide. (A, B, and C) do not help restore carbon dioxide levels as effectively as rebreathing air in the cupped hands or from a paper bag.
When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16 weeks of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation
D.) Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child. (D) is closest to the time when parents would be ready for such classes. (A, B, and C) are not the best times during a pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.
The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A. January 14 to 15 B. January 22 to 23 C. January 29 to 30 D. February 6 to 7
This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30 (C).