HESI review questions

A 1-day old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the infant's first stool. What should the nurse do next? a. document the stool in the infant's record b. send the stool to the laboratory per protocol c. assess the infant for an intestinal obstruction d. notify the health care provider that a tarry stool has been passed

A

A newborn male is circumcised. What is the most essential nursing assessment during the initial postoperative period? a. bleeding b. infection c. shrill, piercing cry d. decreased urine output

A

The nurse is providing care to multiparous client in active labor. The client is requesting something for the pain. What is the nurse's priority intervention. a. examining the client's cervix for dilation and effacement b. determining the client's options by assessing the prescriptions in the chart c. asking her whether she prefers an epidural or something in her intravenous line d. evaluating the fetal monitoring strip to determine the frequency and duration of contractions

A

Three days after birth, a breast-feeding newborn becomes jaundiced. The parents bring the infant to the clinic, and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that the infant has physiologic jaundice. What is the cause of the benign condition? a. immature liver function b. an inability to synthesize bile c. an increased maternal hemoglobin level d. a high hemoglobin and low hematocrit level

A

sitz baths are prescribed for a client with an episiotomy during the postpartum period. How do sitz baths aid in the healing process? a. promoting vasodilation b. cleansing of the perineal tissue c. softening of the incision site d. tightening the rectal sphincter

A

the nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter? a. "i'm not exactly sure how an epidural works" b. "I understand that the epidural might or might not take my pain away." c. "I signed the consent form for an epidural at my last clinic appointment." d. "I'm aware that the epidural could cause my contractions to slow down"

A

A pregnant client is now in the third trimester. the client tells the nurse, "I want to be knocked out for the birth." How should the nurse respond? a. you are worried about too much pain b. you don't want to awake during the birth c. i can understand that because the labor is uncomfortable d. i will tell your healthcare provider about this request

B

An infant was born 30 minutes ago. The nurse is preparing an injection of vitamin K for the newborn. Which dosage and route will the nurse take? a. 1.0-1.5 mg given intramuscularly b. 0.5 to 1.0 mg given IM c. 1.0-1.5 mg given subQ d. 0.5 to 1.0 mg given subQ

B

why should the nurse limit food and oral fluids as a laboring client approaches the second stage of labor? a. the mechanical and chemical digestive processes require energy that is needed for labor b. undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia c. the gastric phase of digestion stimulates the release of hydrochloric acid and may cause dyspepsia d. food and fluid will further aggravate gastric peristalsis, which is already increased because of the stress of labor

B

A nurse is caring for a preterm neonate with physiologic jaundice who requires phototherapy. What is the physiologic mechanism of this therapy? a. stimulates the liver to dispose of the bilirubin b. breaks down the bilirubin into a conjugated form c. facilitates the excretion of bilirubin by activating vitamin K d. dissolves the bilirubin, allowing it to be excreted by the skin

B

A client comes to the clinic for a 6-week postpartum check up. She confides that she is experiencing exhaustion that is not relieved by sleep and feelings of failure as a mother because the infant "cries all of the time." When asked whether she has a support system, she replies that she lives alone. Which response would provide the most accurate information? a. providing information about a local support group b. explaining that it is normal to feel depressed after childbirth c. asking the client questions, using a depression scale d. suggesting that the client find someone who can take care of the baby for 24 hours

C

A client who has had a cesarean birth appears upset. She has been having difficulty breastfeeding for two days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial reaction? A. obtaining the requested formula B. Administering the prescribed pain medication C. Assessing the client's breastfeeding technique D. Notifying the practicioner of the client's request to switch feeding methods

C

a client is admitted to the birthing unit in active labor. An amniotomy is performed by the healthcare provider. Which physiologic alterations does the nurse expect to occur after the procedure? a. diminished vaginal bleeding b. less discomfort with contractions c. progression dilation and effacement d. increased maternal and fetal heart rates

C

while caring for the client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg. Pulse is 72 bpm, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? a. recording these expected findings b. obtaining an order for an oxytocin medication c. asking the client when she last changed the perineal pad d. notifying the primary healthcare provider that the client may be hemorrhaging

C

A new mother asks the nurse administering erythromycin opthalmic oitment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse? a. "it will keep your baby from going blind" b. "this ointment will protect your baby from bright lights" c. "there is a law that newborns must be given this medicine" d. "this antibiotic helps keep babies from contracting eye infections"

D

One hour after birth, a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next? a. Encourage the client to void b. notify the practicioner immediately c. massage the uterus and attempt to express the clots d. continue periodic assessments and record the findings

D

a client is 42 weeks gestation is scheduled for induction of labor. the nurse beings the induction with a piggyback infusion of 15 units of oxytocin. which clinical finding requires the nurse to discontinue the oxytocin infusion? a. contractions that occur every 3 minutes lasting for 60 seconds b. elevation of blood pressure from 110/70 to 135/85 mm Hg during the last 30 minutes c. rupture of membranes with amniotic fluid that contains threads of blood and mucus d. several late fetal heart rate decels that return to baseline after the contractions is over

D

a client who is having difficult labor is found to have cephalopelvic disproportion. Which prescription should the nurse question? a. maintain nothing by mouth NPO status b. start a peripheral intravenous (IV) drip of 35% normal saline c. record fetal heart tones every 15 minutes d. piggy back another 10 unit bag of oxytocin

D

after the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond? a. "I'm going to take your temperature right now" b. "let me check you uterus to see whether it's firm" c. "Turn on your side so I can check the amount of lochia d. "I'll get you some warm blankets to help make the chill go away."

D

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent? a. radiation b. convection c. conduction d. evaporation

d