OB/Maternity HESI Assignment exam

Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routinestanding order for methylergonovine maleate (Methergine)?

A. Pregnancy induced hypertension

A primigravida at 12 weeks gestation who just moved to the United States indicates she has not received any immunizations. Which Immunizations should the nurse administer at this time? (Select all that apply)

A. Tetanus C. Diphtheria E. Hepatitis B

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?

A. Uterine cramping

An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing intervention?

B. Begin humidified oxygen via hood

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?

B. Cephalohematoma

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

C. Place the client in a side-lying position

An infant born at 37 weeks gestation, weighing 4.1 kg is 2 hours old and appears large for gestational age, flushed, and tremulous. What procedure should the nurse follow to implement?

1. Wrap the infant's foot with a heel warmer for 5 minutes 2. Collect a spring-loaded automatic puncture device 3. Restrain the newborn's foot with your free hand 4. Cleanse puncture site on the lateral aspect of the heel

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

A. PICA

A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first?

B. Assess the fetal heart rate and pattern

The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (select all that apply)

B. Chest breathing with nasal flaring C. Diaphragmatic with chest retraction F. Grunting heard with stethoscope

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

B. Put a blanket on the scale when weighing the infant

A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at work, and is not sleeping well. The client's physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results?

B. Using an anticonvulsant for epilepsy

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

B. Visualize the perineum for bulging

A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider?

D. Bilirubin

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?

C. Assess the infant's blood glucose level

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?

D. Caput succedaneum

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

D. Document the finding in the client record

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

D. Vitamin K (AquaMEPHYTON)

A gravid client develops maternal hypotension following regional anesthesia. What interventions should the nurse implement? (Select all that apply)

A. Administer oxygen B. Increase IV fluids E. Place the client in a lateral position F. Monitor fetal status

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

A. Allow formula to flow by gravity

A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give?

A. Apply ice to the breasts

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

A. Avoid alcohol because it is excreted in breast milk

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

A. Decrease in pulse rate

A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next?

A. Determine the firmness of the fundus

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?

A. Fetal well being with labor progression

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

A. Give 10 liters of oxygen via face mask

Which action should the nurse implement caring for a newborn immediately after birth?

A. Keep the newborn's airway clear

The nurse administers meperidine (Demerol) 25 mg IV push to a laboring client, who delivers the infant 90 minutes later. What medication should the nurse anticipate administering to the infant?

A. Naloxone (Narcan)

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

A. Oxytocin (Pitocin)

Which nursing intervention is the priority during the fourth stage of labor?

B. Assess for hemorrhage

The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply)

B. Chest breathing with nasal flaring C. Diaphragmatic with chest retraction F. Grunting heard with a stethoscope

A client who is breastfeeding develops engorged breasts on the third postpartum day. Which action should the nurse recommend to relieve breast engorgement?

B. Continue breastfeeding every 2 hours

The nurse tells a client in her first trimester that she should increase her daily intake of calcium to 1200 mg during pregnancy. The client responds, "I don't like milk." What dietary adjustments should the nurse recommend?

B. Eat more green, leafy vegetables

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

B. Exhibit interest in learning more about infant care

The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make?

B. Explore the mother's concerns about the infant receiving an injection of vitamin K

What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta?

B. Hard, board like abdomen

A client in the first stage of 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?

B. Help her breathe into a paper bag

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?

B. Inform the client to continue breastfeeding

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 would require the nurse to take action?

B. Intensity of contractions is 130 mmHg

During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide?

B. Make sure to include adequate folic acid in the diet

The nurse notes an irregular bluish hue on the sacral area of a 1 day old Hispanic infant. How should the nurse document this finding?

B. Mongolian spots

An infant with hyperbilirubinaemia is receiving phototherapy. What intervention should the nurse implement?

B. Monitor temperature

A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4000 grams. The client's funud is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the fundus, the fundus remains difficult to locate and the rubra lochia remains heavy. What action should the nurse implement next?

B. Notify the healthcare provider

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?

B. Observe the mother for other attachment behaviors

What action should the nurse implement with the family when an infant is born with anencephaly?

B. Prepare the family to explore ways to cope with the imminent death of the infant

Which finding indicates to the nurse that a 4 day old infant is receiving adequate breast milk?

B. Saturates 6 to 8 diapers per day

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 the best advantage of gravity during delivery?

B. Squatting

A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory distress, tahcycardia, and a cutaneous rash. What nursing intervention should be implemented first?

B. Stop the transfusion

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?

B. The fetus can respond to sound by 24-weeks gestation

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?

B. The fetus in utero is capable of hearing and does respond to the mother's voice

A female client who wants to deliver at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide?

B. The pregnancy should progress normally and be considered low risk

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?

B. Ultrasonography

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

C. Canned sardines

The nurse is planning for the care of a 30 year old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome?

C. Degree of glycemic control during pregnancy

Which action is most important for the nurse to implement for a client at 36 weeks gestation with vaginal bleeding?

C. Determine fetal heart rate and maternal vital signs

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

C. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy

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?

C. Document the finding as erythema toxicum

The nurse is assessing a 12 hour old infant with a maternal history of frequent alcohol consumption during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol syndrome (FAS)?

C. Flat nasal bridge

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

C. Monitor blood pressure

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. What action should the nurse implement?

C. Monitor for premature ventricular contractions

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?

C. Observe interactions of family members with the newborn and each other

A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action?

C. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia

A client who is at 24 weeks gestation presents to the emergency department holding her arm and complaining of pain. The client reports she fell down the stairs. Which observation should alert the nurse to a possible battering situation?

C. Other parts of her body have injuries that are in different stages of healing

A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal disturbance, what action should the nurse take?

C. Perform a nitrazine test

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?

C. Place the client in the knee-chest position

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 mmHg at the peak. Based on this information, what action should the nurse implement?

D. Document the findings in the client record

Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor?

D. Encourage early initiation of breast of formula feeding

The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37 weeks gestation. What nursing action should be implemented first?

D. Evaluate the newborn's color and respirations

Which client finding should the nurse document as a positive sign of pregnancy?

D. Fetal heart tones (FHT) heard with a doppler

A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first?

D. Gently rub the infant's feet or back

When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth?

D. Medical backup should be available quickly in case of complications

Which procedure evaluates the effect of fetal movement on fetal heart activity?

D. Non-stress test (NST)

A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement?

D. Notify the healthcare provider

Which finding for a client in labor at 41 weeks gestation requires additional assessment by the nurse?

D. One fetal movement noted in an hour

The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand?

D. Report uterine cramping or low backache

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

D. Respiratory rate of 11 breaths/minute

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

D. Spray with warm water from front to back using a squeeze bottle

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?

D. Striae gravidarum

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

D. Swaddle the infant snugly and hold tightly

The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion?

D. The fetal heart rate is 180 bpm without variability

A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client?

D. The growing uterus is putting pressure on the bladder.

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

D. The heart develops in the third to fifth weeks after conception

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?

D. The pinpoint spots are benign and disappear within 48 hours

A client at 28 weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client?

D. The weight gain is acceptable for the number of weeks pregnant

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

C. Changes in fetal heart rate patterns

A client at 39 weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39 weeks, 34 weeks, and 35 weeks. Using GTPAL, what is the most accurate summary of her history?

B. 4-1-2-0-3

The father of a newborn tells the nurse, "My son just died." how should the nurse respond?

A. "I am sorry for your loss."

Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy?

A. "Protein helps the fetus grow while I am pregnant."

During an assessment of a multiparous client who delivered an 8 lb 7 oz infant 4 hours ago, the nurse notes the client's perineal pad is completely saturated within 15 minutes. What action should the nurse implement next?

A. Perform fundal massage

A client at 35 weeks gestation visits the clinic for a prenatal check up. Which complaint by the client warrants further assessment by the nurse?

A. Periodic abdominal pain

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

C. Count the heart rate for at least one full minute

What action should the nurse implement when caring for a newborn receiving phototherapy?

B. Place an eyeshield over the eyes

A client delivers twins, one is stillborn and the other is recovering in intensive care nursery. As the nurse provides assistance to the bathroom, the client softly crying, states, "I wish my baby could have lived." Which response is best for the nurse to give?

C. "I am sorry for your loss. Do you want to talk about it?"

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide?

C. A large body surface area favors heat loss to the environment

The nurse on the postpartum unit receives report for 4 clients during change of shift. Which client should the nurse assess for risk of postpartum hemorrhage?

C. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia

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?

C. Abdominal ultrasound

The nurse is teaching a primigravida at 10 weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care

C. Adequate folic acid during embryogenesis reduces the incidence of neural tube defects

A client is experiencing "back" labor and complains of intense pain in the lower lumbar-sacral area. What action should the nurse implement?

C. Apply counter pressure against the sacrum

A nulliparous client telephones the labor and delivery unit to report that she is in labor. What action should the nurse implement?

C. Ask the client to describe why she thinks she is in labor

The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement?

C. Assess for abdominal distention

A multigravida client at 35 weeks gestation is diagnosed with pregnancy induced hypertension. Which symptom should the nurse instruct the client to report immediately?

C. Blurred vision

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?

C. Secretes both estrogen and progesterone

Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate?

D. Oral sucrose and nonnutritive sucking

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

D. 3.5 ounces

A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client?

D. Abstinence is strongly recommended throughout the pregnancy

Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)?

D. Primigravida mother who is Rh-negative

The nurse assesses a high risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What nursing action should be implemented?

D. Report findings to the healthcare provider