Family Nursing HESI

Signs of Potential Complications

A - abdominal pain (problem w/liver or gallbladder) C - chest pain, SOB (possible clot problem w/in lungs or heart) H - Headaches (sudden or persistent) (CVA or HTN) E - Eye problems (may indicate cardiovascular accident or HTN) S - Severe leg pain (may indicate thromboembolism)

During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks . The nurse notes the client has 3+ bilateral, pitting , pedal edema. Which action should the nurse implement?

Ask if blurred vision and headache have occured

When is the screening test for PKU done?

At 2-3 days of life, or after enough breast or formula (usually after 24 hours) is ingested to allow for determination of the body's ability to metabolize amino acid phenylalanine.

When assessing a client who is at 12-weeks 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?

At 30-weeks gestation is closest to the time parents would be ready for such classes.

Vaginal discharge-pregnancy During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. What action should the nurse implement?

Can occur in the first through the third trimesters Caused by hypertrophy and thickening of the vaginal mucosa and increased mucus production. Inform her that this is a normal physiological change.

Caput succedaneum Regardless of who performs the physical assessment , the nurse must know normal versus abnormal variations of the newborn. What is the difference between caput succedaneum and cephalhematoma?

Cephalhematoma does NOT cross suture lines and manifests a few hours after birth

The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?

Foods sweetened with aspartame

Parents asking nurse why heel stick is important for baby ?

It is routine exam to check for metabolic deficiency

Best birth control for a breastfeeding mom

NOT the combined pill bc of the estrogen A: condom with spermicide gel (Nothing with hormones in it)

Indigestion-3rd trimester A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?

Take your blood pressure now and if it is seriously elevated, go to the hospital.

Childbirth education A client in the first trimester of pregnancy joins a childbirth education class. During this trimester, the class is most likely to cover which physiologic aspect of pregnancy?

Warning signs of complications

Before advising a client about oral contraceptives, the nurse needs to ?

assessthe client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives.

Prenatal care-type 1 DM A pregnant woman have type 1 diabetes and is going to receives insulin teaching she tells the nurse that she is going to not eat in the morning because religion and is a holy month, what is the nurse best teaching:

collaborative work to create a new insulin schedule

Flexion and extension of the ankle

promotes venous return and helps prevent thrombophlebitis

Pregnancy test hormone

something that can be verified by a provider Ultrasound verification of embryo or fetus (4 to 6 weeks) Fetal movement felt by experienced clinician (20 weeks) Auscultation of fetal heart tones via Doppler (10 to 12 weeks)

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother?

the scalp edema will subside a few days after birth.

Intimate Partner Violence (IPV)

use SAVE screening Screen fir sexual violence Ask direct questions Validate the patient Evaluate, educate, and refer

A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond?

"This is called caput succedaneum. It will absorb and cause no problems."

Oral contraceptives

- Suppress action of hypothalamus & ant. pituitary - Insufficient secretion of FSH & LH - Follicles do not mature, ovulation is inhibited - Endometrium less favorable for implantation - W/drawl bleeding - less profuse & shorter

PKU genetics PKU baby

25% any babies born later will have it too.