HESI-Focus on Maternity Exam

a pregnant woman at 38 weeks gestation arrives at the ED, reporting bright-red vaginal bleeding by denying pain. On the basis of this information, the nurse determines that the client may be experiencing

placenta previa

A nurse assists a pregnant client who is in the second trimester into lithotomy position on the exam table in the OB office. The client suddenly becomes dizzy, lightheaded, nauseated and pale. The nurse immediately

positions the client on her side

a client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 min but has remained at station 0. the FHR on admission was 140bpm and regular. The FHR is slowing and a persistent FHR pattern is present. The appropriate nursing action in this situation is

preparing the client for a c-section

a nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which situation wold the nurse suspect based on this observation

pressure on the fetal head during a contraction

a nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant

prone

a nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. 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 intervention in the care of this client

providing pain relief

a nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. Based on this finding, which nursing action is the priority

administering oxygen by way of face mask

a nurse performing an assessment of a pregnant client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device

12 weeks

a multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as

14-16 weeks gestation

A nurse is performing an assessment of a client who is at 20 weeks gestation. The nurse asks the client to void, then measures the fundal height in cm. Which approximate measurement does the nurse expect to see

20cm

a nurse is assessing the resp rate of a newborn. Which finding would the nurse document as normal

50 breaths/min

a client in the 3rd trimester of pregnancy is complaining of urinary frequency and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures

I need to drink at least 2000mL of fluid a day

a client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction

I need to stay in bed for the rest of my pregnancy

a PP nurse instructs a new mother in how to bathe her newborn. Which statement by the mother indicates a need for further instruction

I should bathe him after a feeding

A nurse is reviewing the criteria for early discharge of a newborn infant. Which, if noted in the infant, would indicate that the criteria for early d/c have been met SATA a) The infant has urinated b) the infant has passed 1 stool c) VS are documented as normal d) the infant has completed one successful feeding e) the infant has shown no evidence of jaundice in the first 6 hours of life

a, b, c

A multigravida woman with a hx of multiple c-sections is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture SATA a) fetal bradycardia b) maternal tachypnea c) excessive vaginal bleeding d) increased uterine contractions e) maternal complaint of sudden sharp abdominal pain

a, b, e

a nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which clients does the nurse recognize as being at risk of the development of DIC SATA a) a client with septicemia b) a client with mild preE c) a client with DM who delivered a 10lbs d) a client who had a c-section b/c of abuptio placentae e) a client who delivered 12 hours ago and has lost 475mL of blood

a, d

a nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis

administering oxygen as prescribed

a nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, "I think my wife is going into shock or something! She was just lying there and the she turned so pale and her hands are so clammy. She said she was dizzy and sick to her stomach/" The nurse notes on the NIBP monitor that the woman's pulse is 58bpm and her BP is 90/50. The nurse interprets these findings as indications that the woman is experiencing

altered tissue perfusion r/t hypotensive syndrome (vena cava syndrome)

A nurse provides instructions regarding PP exercises to a client who has delivered a newborn vaginally. The nurse tells the client that

alternating contraction and relaxation of the muscles of the perineal area should be practiced

A nurse is assisting a HCP in performing a physical exam of a client who has just been told that she is pregnant. The HCP tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of

an increase in vascularity and hypertrophy of the cervix

A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the N&V. the nurse tells the client to

eat carbs such as cereals, rice and pasta

a pregnant client is seen in the clinic for the first time. This is the client's first pregnancy and the client tells the nurse that she has DM. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction SATA a) I need to follow the prescribed diabetic diet b) I need to limit exercise while I'm pregnant c) I need to report signs of infection to my HCP d) My insulin requirements may change while I'm pregnant e) I'll come back for a prenatal visit every month during my first trimester

b, e

a nurse is assessing a newborn with a dx of congenital diaphragmatic hernia. Which assessment finding would the nurse specifically expect to note in the newborn

bowel sounds heard over the chest

a nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae SATA a) a primipara b) a 36 y/o c) a hypertensive client d) a pack a day smoker e) a client who exercises regularly

c, d

a client with preE who is receiving mag sulfate in an IV infusion exhibits signs of mag toxicity. The nurse immediately prepares for the administration of

calcium gluconate

A nurse provides information about the tx for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if s/s of hypoglycemia occur, she must immediately

check her BGL

a nurse is caring for a client experiencing hypotonic contractions. The client is discourage by the lack of progress with labor but refuses an amniotomy or oxytocin stimulation. The nurse determines that the client's behavior may be a result of

concern about her own and the baby's well being

a nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 min apart. The FHR is 170bpm and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate action is

contacting the HCP

a nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client

contractions that begin in the lower abdomen and back and radiate over the entire abdomen

a nurse is assessing the lochia of a client who delivered a viable newborn 1 hour ago. Which type of lochia would the nurse expect to note at this time

dark-red lochia rubra

a nurse is monitoring a client in the third trimester of pregnancy who has a dx of severe preE. Which finding would prompt the nurse to contact the HCP

diaphoresis and tachycardia

a woman with severe preE delivers a healthy newborn infant and continues to recieve mag sulfate therapy in the PP period. 24 hours after delivery, the client begins passing >100mL of urine every hour. The nurse recognizes this volume of UOP as an indication of

diminished edema and vasoconstriction in the brain and kidneys

a client is admitted to the hospital for an emergency c-section. Contractions are occurring every 15 min, the client has a temp of 100 F and the client reports that she last ate 2 hours ago. The client also states that "everything happened so fast" and that she has had no preparation for the c-section. Which action should the nurse take first

reporting the time of last food intake to the HCP

a nurse is performing assessments every 30 min on a client who is receiving mag sulfate for preE. Which finding would prompt the nurse to contact the HCP

resp of 10 breaths/min

A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse

simultaneously provides pressure over the lower uterine segment

a nurse is monitoring a client in labor for sign of intrauterine infection. which sign, indicative of infection, would prompt the nurse to contact the HCP

strong-smelling amniotic fluid

a delivery room nurse is preparing a client for c-section. The client is placed on the delivery room table, and the nurse positions the client

supine with a wedge under the right hip

A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client

that this is a normal postpartum occurence

a nurse is monitoring a FHR. The nurse documents a reassuring FHR pattern in the record on noting

variability of 6-25 bpm

A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate?

this must be hard for you

a pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is

the newborn does have a risk of contraction the infection

a pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and faitgue and TB is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic mgmt of the disease, tells the mother that

the mother may need to take isoniazid, pyrazinamide and rifampin for a total of 9 monhts

a nurse caring for a hospitalized client with a dx of abruptio placentae and develops a nursing care plan incorporating interventions to be implemented in the event of shock. If signs of shock develop, to promote tissue oxygenation, the nurse would immediately

turn the client on her side

placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which finding would the nurse expect to note

uterine tender to palpitation

during a prenatal visit, the nurse notes that an adolescent pregnant client with DM has lost 10lbs during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, "I don't eat regular meals". The appropriate response is

Let's make a list of what you're eating

a nurse notes that the lab report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia and an increased ESR. Which lab test would further confirm the presence of HIV does the nurse anticipate that the HCP will prescribe

T-lymphocyte determination

a nurse is conducting a home visit with a mother and her 1 week old infant, who is at risk for acquired neonatal congenital syphillis. Which finding specific to this disease does the nurse look for while assessing the infant

a copper colored rash

a nurse palpates the anterior fontanel of a neonate and notes that it feels soft. This interprets this assessment data as

a normal finding

RhoGam is prescribed for a client after delivery. Before administering the med, the nurse reviews the client's hx. Which finding is a contraindication to administration of the med

a previous hypersensitivity reaction to immune globulin

A rubella antibody screen is performed in a pregnant client, and the result indicate that the client is not immune to rubella. The nurse tells the client that

a rubella vaccine must be administered after childbirth

A woman in labor suddenly experiences CP and dyspnea and the nurse suspects the presence of amniotic fluid embolism. The nurse immediately

administers oxygen to the woman

a nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as most likely the result of

anxiety and the need for support

a nurse is providing nutritional counseling to pregnant client with a hx of cardiac disease. What does the nurse advise the client to eat

apple and whole-grain toast

a nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first

ask the client to empty her bladder

a postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity

in 2-4 weeks

A nurse performing an assessment of a pregnant client is preparing to take the client's BP. the nurse positions the client

in a sitting position with the arm in a horizontal position at heart level

a clinic nurse is performing an assessment of an HIV positive woman during the 32 week of gestation. Which finding requires further follow up

increased SOB and bilateral crackles in the lungs

a nurse is monitoring a pregnant client with sepsis for DIC. Which lab finding causes the nurse to suspect DIC

increased fibrin degradation products

A nurse is monitoring a client who was given an epidural opioid for a c-section. The nurse notes that the client's oxygen saturation on a pulse ox is 92%. the nurse first

instructs the client to take several deep breaths

Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially

instructs the mother to push when signs of separation have occurred

after the delivery of a newborn, a nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating that the infant

is adjusting well to extrauterine life

a woman being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort

eat dry crackers every 2 hours to prevent an empty stomach

a nurse teaches a new mother how to perform umbilical cord care and how to recognize the signs of a cord infection. Which finding does the nurse tell the mother is an indicator of infection

edema at the base of the cord

a nurse is preparing to assess the FHR in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse use to assess the FHR

electronic dopple

A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temp and notes that it is 100.4 F. The most appropriate nursing action would be to

encourage the intake of oral fluids

A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL (8.6 mmol/L). The nurse tells the client that:

additional tests will likely be performed to confirm gestational diabetes

A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle crap) about tx of the condition. the nurse tells the mother to

apply oil to the affected area on the infant's scalp

A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contraction. The nurse tells the client these contractions

are a common occurrence of pregnancy

After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to:

assist in repositioning the uterus through the vagina into a normal position

a nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to

gently massage the breasts during breastfeeding to help empty the breasts

A nurse is caring for a PP client who had a low-lying placenta. The nurse assesses the client most closely for

hemorrhage

a clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care

hx of IV drug use

a nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder

do you have sharp pain on the right or left side of your pelvis

A nurse assessing a pregnant client's DTR notes a reflex of 2+. The nurse should

document the finding

A nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the nurse perform in response to this observation

document the finding

a nurse is changing the diaper of a 1 day old full term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that the appropriate action is

document the findings

a nurse is assessing a newborn infant with a dx of gastroschisis. The nurse expects to note that the bowel is located

outside the abdominal cavity and not covered with a sac

A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to

perform kegel exercises in 10 repetitions, three times per day

a nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement

performing a sudden tap on the cervix

a nurse provides instructions regarding prenatal care to a client with a hx of heart disease. The nurse tells the client that

physical activity should be limited

A nurse is caring for a client with preE who is receiving a mag sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the med is effective

the client experiences diuresis within 24 to 48 hours

after an unplanned c-section, the nurse finds the client in emotional distress, tearfully expressing bewilderment, sadness and feelings of failure and regret b/c she could not deliver vaginally. Which conclusion should the nurse make

the client is experiencing low self-esteem

A Hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that

the infant should receive both the vaccine and hepatitis immune globulin soon after birth

a nurse is reviewing the medical record of a pregnant client with sickle cell anemia. To which information related by the client would the nurse give the highest priority

drinking less than 4 glasses of fluid daily

A nurse instructs a pregnancy client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid

lima beans

a nurse is preparing to care for a client experiencing dystocia. To which intervention does the nurse give priority

monitoring fetal status

A neonate is irritable, cries incessantly, and has a temperature of 99.4° F (37.4°C). The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with:

neonatal abstinence syndrome

a nonstress test is performed and the HCP documents "accelerations lasting than 15 sec throughout fetal movement". The nurse interprets these fidnings as

nonreactive

A nurse is caring for a client receiving an IV infusion of oxytocin to stimulate labor. Which finding would prompt the nurse to stop the infusion

nonreassuring FHR patter

A delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. Based on this finding, which nursing action is appropriate initially

notifying the HCP

a nurse is monitoring a newborn who has been admitted to the nursery. The nurse notes that the anterior fontanel measures 4cm and bulges when the infant is at rest. Based on this observation, what is the appropriate nursing action

notifying the HCP

a pregnant woman reports that she has just finished taking the prescribed abx to treat her UTI but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears

now that you have taken the med as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today