Maternity HESI

A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's BEST response?

"Please share with me more about your concerns."

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a NEED FOR FURTHER INSTRUCTION?

"I will maintain strict bed rest throughout the remainder of the pregnancy."

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that FURTHER TEACHING IS NEEDED if the client makes which statement?

"I will need to increase my insulin dosage during the first 3 months of pregnancy."

A nursing student is assigned to care for a client in labor. The nursing student instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus?

"It connects the umbilical vein to the inferior vena cava."

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's BEST response?

"It promotes the fertilized ovum's normal implantation in the top portion of the uterus."

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will not be as painful if I walk around."

A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps?

"Bend your foot toward your body while extending the knee when the cramps occur."

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be MOST APPROPRIATE?

"Do you plan to have any other children?"

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a NEED FOR FURTHER INSTRUCTIONS?

"I need to lie flat on my back to perform the procedure."

The nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a NEED FOR FURTHER INSTRUCTIONS?

"I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates and understanding of the instructions?

"I should avoid eating foods that produce gas and fatty foods."

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a NEED FOR FURTHER TEACHING?

"I should avoid exercise because of the negative effects on insulin production."

The nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I should drink adequate fluids and increase my intake of high-fiber foods."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?

"I should wash my nipples daily with soap and water."

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement(s)? Select all that apply.

"I should wear a bra that provides support."

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a NEED FOR FURTHER INSTRUCTIONS?

"I should wear knee-high hose but I should not leave them on longer that 8 hours."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client?

"The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel."

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

"The vaginal discharge may be bothersome, but is a normal occurrence."

The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan?

"Two arteries carry deoxygenated blood from the placenta to the fetus."

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?

"What can I do for you?"

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn."

The nurse should include which statement to a pregnant client found to have a gynecoid pelvis?

"Your type of pelvis is the most favorable for labor and birth."

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area?

1 cm above the ischial spine

The nursing instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? SELECT ALL THAT APPLY.

1. Allows for fetal movement. 2. Surrounds, cushions, and protects the fetus. 3. Maintains the body temperature of the fetus. 4. Can be used to measure fetal kidney function

The nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which are probable signs of pregnancy? SELECT ALL THAT APPLY.

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply.

1. Bright red vaginal bleeding. 2. Soft, relaxed, nontender uterus. 3. Fundal height may be greater than expected for gestational age.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? SELECT ALL THAT APPLY.

1. Pregnancy needs to be avoided for 1-3 months. 2. The vaccine is administered subQ. 3. Exposure to immunosuppressed individuals needs to be avoided. 4. A hypersensitivity reaction can occur if the client has an allergy to eggs.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? SELECT ALL THAT APPLY.

1. Proteinuria 2. Hypertension 3. Generalized edema

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

1.Wear a supportive bra. 2.Rest during the acute phase. 3.Maintain a fluid intake of at least 3000 mL. 4.Continue to breast-feed if the breasts are not too sore.

A pregnant client asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

14 and 18

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum

The nurse is performing an assessment of a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and expects which finding?

30 cm

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instructions should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)?

A client who has a history of intravenous drug use.

The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being at the MOST risk for developing disseminated intravascular coagulation?

A gravida II who has just been diagnosed with dead fetus syndrome.

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

A normal test result

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. This finding is most closely associated with which characteristic?

A softening of the cervix

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

Assess the baseline fetal heart rate.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?

Administer oxygen, 8 to 10 L/minute, by face mask.

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

Administer oxygen, 8-10 L/minute via face mask.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats/minute

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

An informed consent needs to be signed before the procedure.

Which explanation should the nurse provide to the prenatal client about the purpose of the placenta?

It is the way the baby gets food and oxygen.

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

Bring the infant to the clinic.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?

Delivery of the fetus

The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin (Pitocin).

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket.

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client?

Encourage fluid intake

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins

The nurse is performing an assessment on a pregnant client with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is MOST closely associated with a complication of this diagnosis?

Evidence of bleeding, such as in the gums, petechiae, and purpura.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider?

Fetal heart rate of 180 beats/minute.

Which assessment finding following an amniotomy should be conducted first?

Fetal heart rate pattern.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of and type of abortion or fetal demise. Using GTPAL what should the nurse document in the client's chart?

G-2, T-1, P-0, A-0, L-1

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding?

Heavy

A pregnant client tells the nurse that she has been craving "unusual foods." The nurse fathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice?

Hemoglobin 9.2 g/dL

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia?

Hypotonic.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action?

Increase hydration by encouraging oral fluids.

The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding w0uld be normal for a client in the second trimester?

Increase in pulse rate.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy?

Increased efficiency of contractions.

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is MOST APPROPRIATE?

Inform the client that these contractions are common and may occur throughout the pregnancy.

The health care provider (HCP) is assessing the client for the presence of ballottement (technique to examine a floating object in the body). To make this determination, the HCP should take which action?

Initiate a gentle upward tap on the cervix.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate?

Instruct the client to request help when getting out of bed.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?

Isoniazid plus rifampin (Rifadin) will be required for 9 months.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using Nagels's rule, which expected date of delivery should the nurse document in the client's chart?

July 26, 2015.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate?

Massage the fundus until it is firm.

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?

Massage the fundus until it is firm.

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate.

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding?

Normal

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action?

Notify the health care provider (HCP)

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?

Notify the health care provider (HCP)

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the PRIORITY nursing action?

Notify the health care provider (HCP)

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Notify the health care provider.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

Perform a vaginal examination every shift.

The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?

Place the client in Trendelenburg's position.

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?

Prepare an ice pack for application to the area.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

Supine position with a wedge under the right hip

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant.

A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell the client that which exercise is safest?

Swimming

A pregnant client tells the clinic nurse that she wants to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks' gestation because of which factor?

The appearance of the fetal external genitalia

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?

The cervix is dilated completely.

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider?

The client complains of a headache and blurred vision.

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

The client has a history of cardiac disease.

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action?

The client with lochia that is red and has a foul-smelling odor.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action BEST exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine tenderness

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

The nurse is providing instruction to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide?

Wash the breasts with warm water and keep them dry.