Maternity HESI Assignment Exam

A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding?

3.5 ounces. Rationale: A newborn requires approximately 19 to 21 ounces of formula each day (six feedings per 24-hour period x 3.5 = 21).

A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client?

Abdominal ultrasound. Rationale: Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an indicator of placenta previa, which is confirmed by abdominal ultrasound.

What nursing action should be implemented when intermittently gavage-feeding a preterm infant?

Allow formula to flow by gravity. Rationale: Gavage feeding is commonly used to feed preterm infants who are born at less than 32-weeks gestation, infants who weigh less than 1500 grams, or infants who are unable to tolerate oral feedings. The feeding should flow by gravity to avoid over-distention and a sudden sensation of fullness that may cause vomiting.

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?

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.

A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which food should the nurse recommend to increase the client's calcium intake?

Canned sardines. Rationale: A 3 ounce can of sardines (with bones) provides about the same amount of calcium as 1 cup of milk.

While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document?

Cephalohematoma. Rationale: A cephalohematoma should be documented because it is a collection of blood beneath the periosteum of the cranial bone causing scalp swelling that does not cross the suture line.

A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage?

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.

A 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.

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.

When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?

Count the heart rate for at least one full minute. Rationale: It is most important for the nurse to count the heart rate for at least one full minute so that irregularities or murmurs can be detected.

Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation?

Decrease in pulse rate. Rationale: Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 beats/minute, which persists to term, so a decrease should be assessed further.

When assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next?

Document the finding as erythema toxicum. Rationale: Erythema toxicum, or newborn rash, is a normal, transient rash that is found in term neonates during the first 3 weeks of age. No treatment is required, so documenting the finding as erythema toxicum should be implemented.

Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day?

Exhibit interest in learning more about infant care. Rationale: By the third postpartum day, the new mother should start to "take hold" of caring for her infant, by asking questions about infant care and initiating care of her infant.

A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. What action should the nurse implement next?

Notify the healthcare provider. Rationale: Treatment of excessive bleeding requires the collaboration of the healthcare provider.

A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time?

Observe interactions of family members with the newborn and each other. Rationale: An opportunity to assess the emotional adjustment of individual family members to birth and lifestyle changes is presented, so the nurse should first observe the interaction of the family members.

A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide?

Secretes both estrogen and progesterone. Rationale: One of the early functions of the placenta as an endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone, necessary to maintain the pregnancy and support the embryo and fetus.

A 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?

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.

The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Heart rate of 158 beats per minute. Grunting heard with a stethoscope.

Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant.

The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Rate of 58 breaths per minute. Grunting heard with a stethoscope.

Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant.

While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding?

Caput succedaneum. Rationale: Caput succedaneum is characterized by swelling of the soft tissues of the scalp that extends across suture lines.

The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide?

Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy. Rationale: The major risk after a molar pregnancy is the development of choriocarcinoma, which is detected by measuring the same hormone (hCG) that the body produces during pregnancy. Continued elevated hCG levels may be either from choriocarcinoma or a subsequent pregnancy making diagnosis and treatment difficult, so oral contraceptives are prescribed to prevent pregnancy for a year since it interferes with monitoring the return of hCG levels to normal.

A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to baseline before each contraction ends. What action should the nurse implement?

Document the finding in the client record. Rationale: Early FHR decelerations are a normal finding during active labor that occurs due to fetal head compression, so the finding should be documented in the client record.

A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this information, what action should the nurse implement?

Document the findings in the client record. Rationale: This labor pattern indicates that the client is in the active phase of the first stage of labor and has a normal labor pattern, so the findings should be documented in the client's medical record.

A client with asthma who is 8 hours post-delivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer?

Oxytocin (Pitocin). Rationale: Oxytocin is the drug of choice, and it will not exacerbate symptoms of asthma.

While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change?

Fetal well being with labor progression. Rationale: Fetal heart rate accelerations that last 15 to 20 seconds are a sign of fetal well-being, so continuous external fetal monitoring should be continued.

The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement?

Give 10 liters of oxygen via face mask. Rationale: Late decelerations occur when there is reduced placental and fetal perfusion. Administering oxygen increases the oxygen saturation in the blood thus increasing oxygen to the fetus.

A client in the first stage of active labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light-headed, dizzy, and states that her fingers are tingling. What action should the nurse implement?

Help her breathe into a paper bag. Rationale: Hyperventilation can precipitate respiratory alkalosis and cause light-headedness, dizziness, tingling of the fingers, and circumoral numbness. Breathing into a paper bag held tightly around the mouth and nose enables the client to rebreathe carbon dioxide, which reduces depletion of carbonic acid. and compensates for the respiratory alkalosis.

A client comes in to the clinic for her six week postpartum check up and complains that her left breast is eythematous and painful. The client asks, "Can I still breastfeed my baby?" What is the best response for the nurse to provide?

Inform the client to continue breastfeeding. Rationale: The client should be encouraged to continue breastfeeding because emptying the breast helps alleviate the pain and prevents abscess formation.

A client in labor receives an epidural block. What intervention should the nurse implement first?

Monitor blood pressure. Rationale: The risk for maternal hypotension is commonly increased by an epidural, so blood pressure should be monitored immediately after the first epidural dose and for 15 minutes thereafter.

The 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?

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.

A client delivers her first infant and asks the nurse if her skin changes from pregnancy are permanent. Which change should the nurse tell the client will remain after pregnancy?

Striae gravidarum. Rationale: Striae gravidarum, or "stretch marks," occur on the lower abdomen of pregnant women during the second half of pregnancy fade after delivery but do not disappear entirely because they reflect separation within the underlying connective (collagen) tissue of the skin.

What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal ?

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.

A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding should require the nurse to implement further action?

Intensity of contractions is 130 mm Hg. Rationale: The goal of induction of labor with oxytocin is to produce an effective labor, which can be measured by an IUPC reading of 40 to 90 mm Hg for contractions when giving oxytocin.

The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment?

Monitor for premature ventricular contractions. Rationale: During and following the insertion of a pulmonary artery catheter (PAC), ECG activity should be monitored for the occurrence of any ventricular ectopy.

Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks gestation?

Pica. Rationale: Pica, the consumption of low- or non-nutrient substances, may cause more nutritious foods to be displaced from the diet, and depending on the substance ingested, may be toxic or interfere with the absorption of nutrients and minerals.

The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement?

Place the client in a side-lying position. Rationale: Variable decelerations are caused by compression of the umbilical cord and are evidenced by V shape appearance,characterized by a rapid descent and ascent to and from the depth of the deceleration. To alleviate the pressure on the umbilical cord, the nurse should reposition the client into a side-lying position.

A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement first?

Place the client in the knee-chest position. Rationale: Until an emergency delivery is accomplished, the client should be placed in a knee-chest position to relieve compression of the presenting part on the umbilical cord, which can compromise fetal oxygenation.

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)?

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.

What action should the nurse implement to prevent conductive heat loss in a newborn?

Put a blanket on the scale when weighing the infant. Rationale: Placing a blanket on the scale provides a barrier to prevent conductive heat loss when the infant's body comes in contact with a cooler solid surface.

A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider?

Respiratory rate of 11 breaths/minute. Rationale: A sign of magnesium toxicity is respiratory depression, so the client's respiration rate of 11 breaths/minute should be reported to the healthcare provider.

What information should the nurse include about perineal self-care for a client who is 24-hours post delivery?

Spray warm water from front to back using a squeeze bottle. Rationale: A postpartum client should use a squeeze bottle after each void and clean from front to back.

A 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?

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.

A 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?

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.

A client at 8-weeks gestation ask the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur?

The heart develops in the third to fifth weeks after conception. Rationale: The cardiovascular system is the first organ system to develop and function in the embryo. The blood vessel and blood formation begin in the third week, and the heart is developmentally complete in the fifth week.

The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first?

The nurse should first assess the infant's blood glucose level, because the infant is displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy demands.

An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding?

The pinpoint spots are benign and disappear within 48 hours. Rationale: Rapid delivery and a tight nuchal cord cause the presenting parts (head) to have bruising and pin point hemorrhages (petechiae), which are benign and usually disappear within two days after birth.

A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client?

Ultrasonography. Rationale: Gestational age, fetal growth, and the status and position of the placenta are monitored by ultrasound.

At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention?

Uterine cramping. Rationale: The client should be monitored for 1 to 2 hours following the procedure for the occurrence of uterine cramping so that immediate intervention to decrease the risk of miscarriage can be initiated. This procedure (removal of a small piece of tissue from the fetal portion of the placenta) may cause initiation of labor.

A multiparous client is bearing down with contractions and crying out, "The baby is coming!" Which immediate action should the nurse implement?

Visualize the perineum for bulging. Rationale: The perineum should be visualized for bulging or the presentation of the baby so assistance with the impending birth can be immediately rendered.

Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma?

Vitamin K (AquaMEPHYTON). Rationale: The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels and reduce the risk of neonatal bleeding, newborns receive a single injection of vitamin K (AquaMEPHYTON).