HESI Prep 1 (NC 11)

A nurse is teaching breast-feeding to a newly delivered client. Which statement by the client indicates the need for further instruction?

"I need to wash my breasts with soapy water before I breast-feed." Rationale Soap irritates, cracks, and dries breasts and nipples, making it painful for the mother when the baby sucks; it also increases the risk for mastitis. The client should empty the breasts at each feeding to keep milk flowing. Alternating between breasts to start feedings is a permissible and often-used technique of breast-feeding. Gently stroking the baby's cheek elicits the rooting reflex; the infant's head turns toward and touches the mother's breast.

A client who is breastfeeding is being discharged. The client tells the nurse that she is worried because her neighbor's breasts "dried up" when she got home and she had to discontinue breastfeeding. How should the nurse reply?

"That can happen with the excitement of going home; however, putting the baby to the breast more often should get lactation going again." Rationale Often the emotional excitement of going home will diminish lactation or the let-down reflex for a brief period. When the mother is aware that this may happen and knows how to cope, the problem is apt to be a minor one and easily overcome. Stating that this rarely happens once lactation is established constitutes false reassurance. Many factors (stresses) inhibit lactation, and the client should be aware of this. Stating that the client has little to worry about because she already has a good milk supply also constitutes false reassurance. The milk supply may diminish or stop under stress. Giving the client a bottle of formula is contraindicated; lack of breast stimulation during formula feeding could diminish lactation.

A new mother wishes to breast-feed her infant and asks the nurse whether she needs to alter her diet. How should the nurse respond?

"You'll need greater amounts of the same foods you've been eating and more fluids." Rationale Compared with the prenatal diet, the diet for lactation requires an increased intake of all food groups, vitamins, and minerals, plus increased fluid to replace that lost with milk secretion. Breast-feeding mothers need an additional 340 calories and 25 g of protein per day more than nonpregnant needs to maintain adequate milk production. The client needs additional calories, not just additional milk. Telling the client that her body produces the milk her baby needs as a result of the vigorous suckling does not address the mother's concern; optimal nutrition is necessary to produce an adequate milk supply.

One minute after birth a nurse assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry, moves all extremities well, and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score

8 Rationale A heart rate slower than 100 beats/min receives 1 point, and color (acrocyanosis—body pink, extremities blue) receives 1 point; the respiratory rate (strong, loud cry), muscle tone, and reflex irritability each get a score of 2, for a total of 8. A score of 9 is too high. An Apgar score of 7 is too low, as is a score of 6.

A client is found to have gestational hypertension in the twenty-second week of gestation. Which major complication of hypertensive disease associated with pregnancy should the nurse anticipate?

Abruptio placentae Rationale Vasospasms of placental vessels occur because of increased blood pressure. As a result the placenta may separate prematurely ( abruptio placentae). Placenta previa is an abnormal placental implantation and is not related to hypertension. Polyhydramnios, an excessive amount of amniotic fluid, is not associated with hypertensive disorders of pregnancy. Isoimmunization in pregnancy is associated with Rh incompatibility, not hypertension.

A client undergoes a cesarean birth because of cephalopelvic disproportion. What care is needed for this client in addition to the routine nursing care given to all postpartum clients during the first 24 hours?

Administering the prescribed pain medication Rationale Because of increased pain and increased flatus, clients who have had cesarean births require more pain medication than do women who have vaginal births. Early ambulation is encouraged for all postpartum clients. Although this may be difficult because of the incision, palpating the fundus is a necessary part of postpartum care. Vital signs are checked routinely in all postpartum clients.

A client in her tenth week of pregnancy exhibits presumptive signs of pregnancy. Which clinical findings may the nurse determine upon assessment? Select all that apply.

Amenorrhea Breast changes Urinary frequency Rationale The key to answering this question is understanding the difference between presumptive versus probable signs of pregnancy. Presumptive signs of pregnancy are less specific subjective changes that are reported by the client during an assessment interview. Probable signs of pregnancy are more objective changes that can be measured in the reproductive organs during a physical assessment. The absence of menstruation (amenorrhea) is a presumptive sign of pregnancy that is recognized at 4-weeks' gestation. Breast changes, related to increased levels of estrogen and progesterone, are a presumptive sign of pregnancy that is recognized at 3- to 4-weeks' gestation. Urinary frequency, related to pressure of the enlarging uterus on the urinary bladder, is a presumptive sign of pregnancy that is recognized at 6- to 12-weeks' gestation. Abdominal enlargement related to the enlarging uterus is a probable sign of pregnancy that is recognized when the enlarging uterus rises out of the pelvis at 14- to 16-weeks' gestation. A positive urine pregnancy test result, indicating an increase in human chorionic gonadotropin (hCG), is a probable sign of pregnancy that can be detected 26 days after conception.

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?

Asking the client questions, using a postpartum depression scale Rationale A postpartum depression scale is a validated tool for identifying women who might be experiencing postpartum depression. The most widely used and validated tools are the Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale. Although providing community resources of a local support group may be helpful, it is not useful in assessing the client's current emotional status. Although postpartum blues caused by hormonal changes soon after pregnancy might be common, feelings of depression and fatigue 6 weeks after childbirth is a matter of concern. The client may not have anyone else who can provide child care, or the client may not follow through on the recommendation. In addition, this intervention does not provide any information on the client's current emotional status.

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include?

Assessing respirations, keeping him warm, and identifying him Rationale Establishing a patent airway, diminishing cold stress, and identifying the newborn are the priorities. Application of eye prophylaxis and administration of vitamin K are often delayed to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.

After a client gives birth she has the following vital signs: temperature 99.4° F (37.4° C); pulse rate 80 beats/min and regular; respiratory rate of 16 breaths/min, with even respirations; and blood pressure of 148/92 mm Hg. Which vital sign should the nurse continue to monitor closely?

Blood pressure Rationale This client's blood pressure is high. Gestational hypertension may occur during the early postpartum period, and the blood pressure should be monitored. If it returns to a healthy level within 12 weeks, it is called transient hypertension. The pulse rate is within expected limits. A temperature of 99.4° F (37.4° C) is a normal physiologic response after labor, the result of exertion, stress, and mild dehydration. The respiratory rate is within expected limits.

At 20 hours of age a newborn is found to have a bilirubin concentration of 13 mg/dL (274 mcmol/L). Which finding most likely contributed to this bilirubin level?

Cephalhematoma Rationale Cephalhematoma, bleeding into the periosteum of the skull, leads to hyperbilirubinemia. A child with a clubfoot does not have an increased risk of hyperbilirubinemia. Caput succedaneum is edema of the presenting part. It does not involve any bleeding. The postmature infant can better handle the bilirubin than the preterm infant.

A pregnant client is diagnosed with gestational hypertension. The client tells the nurse that she has been following the recommended pregnancy diet. What should the nurse teach her about her diet at this time?

Change nothing Rationale The recommended diet for a client with gestational hypertension is the same as that recommended for a normotensive pregnant client. Protein intake should be increased during pregnancy. Pregnant clients with gestational hypertension should not restrict their sodium intake or increase their carbohydrate intake over the recommended amount.

The charge nurse is delegating tasks for the nursing assistants regarding the postpartum care of a client. Which task is appropriate to be delegated to an unlicensed assistive personnel (UAP) to provide effective client care? Select all that apply.

Feeding the client Providing basic hygiene Encouraging breastfeeding Rationale The UAP can feed the client in postpartum care, provide basic hygiene by assisting in changing sanitary napkins, and provide encouragement for breastfeeding. Teaching care of the infant is not provided by the UAP. The UAP is not eligible and does not have the knowledge to administer intravenous fluids.

The nurse is providing nutrition teaching to a 22-year-old primipara who is 6 weeks pregnant. To decrease the occurrence of neural tube defects in newborns, the nurse would encourage the adequate intake of what nutrient?

Folic Acid Rationale Women who take 0.4 mg/day of folic acid during the 4 weeks before pregnancy and during the first trimester reduce the risk of having an infant with a neural tube defect. Vitamins A and B 12 and niacin should be included in a balanced diet but do not have the effect on neural tube development that folic acid has.

Which prenatal teaching is most applicable for a client who is between 13 and 24 weeks' gestation?

Growth of the fetus, personal hygiene, and nutritional guidance Rationale Awareness of the fetus as an individual and the expected changes of pregnancy lead the client to seek information regarding fetal growth, body changes, and nutrition. Information on infant care, travel to the hospital, signs of labor, signs of preeclampsia, and relaxation breathing techniques is appropriate in the last trimester. Interventions for nausea and vomiting, urinary frequency, and anticipated care are appropriate for the first trimester.

A 6-week-old infant and his mother arrive in the emergency department in an ambulance. The father arrives several minutes later with two children, 7 and 9 years old. The infant is not breathing, and the eventual diagnosis is sudden infant death syndrome (SIDS). The parents take turns holding the infant in another room. The nurse remains present and provides emotional support to the parents. What is an important short-term goal for this family?

Including the infant's siblings in the events and grieving in the wake of the infant's death The other children need to be involved with the grieving process and to work through their own feelings. Identifying the problems that the family will be facing in regard to the loss of the infant is a long-term goal. It is too early to seek out other families who have lost infants to SIDS and receive support from them. It is premature to accept that there was nothing that the family could have done to prevent the infant's death; in fact, they may never achieve this goal.

A client visits the prenatal clinic because her menstrual period is late. Her last period was April 5. Testing confirms that she is pregnant. According to Nägele's rule, what date should the nurse provide as the expected date of birth (EDB)?

January 12 Rationale January 12 is the EDB. Using Nägele's rule, subtract 3 months and add 7 days from the client's last menstrual period. January 5, January 19, and January 26 all represent inaccurate applications of Nägele's rule.

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). Which clinical finding confirms this complication?

Jaundice that develops in the first 12 to 24 hours Rationale The development of jaundice in the first 24 hours indicates hemolytic disease of the newborn. Muscle irritability may or may not be present during the first 24 hours; usually it develops later. Neurologic signs may or may not be present during the first 24 hours; they are dependent on the bilirubin level. Serum bilirubin is expected to accumulate in the neonatal period because of the short life span of fetal erythrocytes, reaching a level of 7 mg/100 mL (100 mcmol/L) the second to third day when jaundice appears (physiologic jaundice).

During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply.

Lethargy Ambivalence Emotional lability Rationale Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is also associated with postpartum depression.

The nurse should be concerned about a client's mother-infant bonding if the client is reluctant to do what on the first postpartum day?

Look at her newborn's face Rationale Looking at the face or seeking eye-to-eye contact with the infant is an early sign of the initiation of bonding with the infant. The mother may feel inept or worry about upsetting the nurse by undressing her infant; new mothers need encouragement to undress their infants. Refusing to breast-feed her newborn may indicate that the mother is worried that she does not have enough milk, a common concern. The client may have attended prenatal classes, may be otherwise occupied, may not be feeling well enough to attend the class, or may feel that she has enough experience to care for her infant without attending a class for newborn care.

A client visits the prenatal clinic for the first time. The client tells the nurse that her last menstrual period began June 10. The nurse uses the Nägele rule to calculate the EDB. What is the EDB?

March 17 Rationale The EDB is March 17. Using the Nägele rule, subtract 3 months and add 1 year and 7 days to the first day of the last menstrual period. April 7, March 7, and April 10 all represent inaccurate applications of the Nägele rule.

Which information concerning the childbearing process should the nurse teach a client during the first trimester of pregnancy?

Physical and emotional changes resulting from pregnancy Rationale Increasing the client's knowledge of physical and psychologic changes resulting from pregnancy prepares the client for expected changes as pregnancy continues; it is most effective when taught during the first trimester. It is too early to teach about labor and birth; this should be done in the last trimester. The client should be alerted to danger signs and symptoms; however, primary teaching is directed toward increasing her knowledge of expected physiological changes. Concerns about role transition to parenthood should be addressed in the third trimester.

What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply.

Refrain from smoking around the infant. Refrain from co-sleeping or bed-sharing. Refrain from placing stuffed toys on the infant's bed. Rationale The nurse should instruct the parents to avoid exposing the infant to cigarette smoke because the chemicals place the infant at a greater risk for sudden infant death syndrome (SIDS). Co-sleeping or bed-sharing is also associated with SIDS. The nurse should ask the parents to refrain from placing stuffed toys on the infant's bed as a precautionary measure against SIDS. The infant should be positioned on his or her back to reduce the incidence of SIDS. Parents should not use soft mattresses or pillows in the infant's crib to reduce the risk for SIDS.

A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. What should the nurse instruct the client to do?

Start feedings on the unaffected breast until the affected breast heals. Rationale The most vigorous suckling occurs during the first few minutes of nursing, as the infant suckles on the unaffected breast; suckling on the affected breast later is less traumatic. Stopping nursing for several days is unnecessary and will interfere with lactation. Manual expression may not completely empty the breast, interfering with lactation. A breast shield confuses an infant because it requires a different suckling pattern to obtain milk.

A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate nursing action in response to this Apgar score?

Start resuscitation Rationale An Apgar score of 3 indicates a severely depressed newborn with apnea, slow heart rate, and an absence of reflexes; resuscitation should be ongoing and should have been started before 1 minute had elapsed. A patent airway must be established before oxygen is administered. Although thermoregulation is important, establishing a patent airway and initiating respiration are of greater importance. Stimulation efforts are ineffective for a neonate who requires resuscitative measures.

The nurse is providing discharge teaching to the parents of a 3-day-old infant. The mother expresses concern regarding sudden infant death syndrome (SIDS). To reduce the risk of SIDS during sleep, how does the nurse instruct the parents to position the infant?

Supine Rationale Studies have shown that SIDS occurs less frequently in infants who are placed in the supine position for sleep. This position allows maximal air movement. Placing an infant in the prone position may increase the risk of upper airway obstruction and rebreathing of expired air. Infants placed on their sides may roll forward into a prone position. Because an adult may roll onto an infant when they are sleeping in the same bed, this practice is not encouraged.

What should the nurse teach the young mother about the nutritional needs of the newborn?

The newborn should be breastfed for the first twelve months. Rationale The nurse recommends breastfeeding for the first 12 months. After the first year, the infant may change to whole cow's milk. If breast feeding is not possible, the newborn should be fed on iron-fortified commercially prepared formula. Whole milk, 2% milk, or alternate milk products should not be given to an infant below 12 months of age because these products can cause intestinal bleeding, anemia, and increased incidence of allergies. Solid foods are not recommended for infants under six months of age because the extrusion reflex pushes the food out of the mouth. The breastfed infant absorbs adequate iron from breast milk during the first four to six months of life. After six months iron-fortified cereal may be given to the infant.

The nurse assures a breast-feeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested?

Voids six or more times a day Rationale The presence of at least six to eight wet diapers each day indicates sufficient breast milk intake. Several firm stools daily may indicate an inadequate amount of fluid ingestion; the stools of breast-feeding neonates should be soft to loose. Spitting out a pacifier is not an indication of adequate milk consumption; some infants need extra sucking stimulation. Awakening to feed every 4 hours is not a reliable indicator of adequate breast milk intake; sleep patterns vary.

A client attending a prenatal class about nutrition tells the nurse that she is a strict vegetarian (vegan). What should the nurse encourage the client to eat that includes all of the essential amino acids?

Whole-grain cereals and nuts This combination provides a complete protein for vegans because they do not eat foods from animal sources, which contain all of the essential amino acids. Macaroni and cheese provides a complete protein and is acceptable to ovo-lacto-vegetarians, who eat milk, eggs, and cheese, but is not acceptable to vegans. Eggs are a complete protein, but are not acceptable to vegans, only to ovo-lacto-vegetarians, who eat milk, eggs, and cheese. Brown rice and whole-wheat bread are both unrefined grains, but together they do not provide a complete protein.