Hesi V1
A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan?
"Another method of contraception is needed until the sperm count is 0"
A postpartum primiparous client is having difficult breast-feeding her infant. The infant latches on the breast, but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breast-feeding when she states:
"As long as some of my nipple is in the baby's mouth, the baby will receive enough milk"
A diabetic postpartum client plans to breast-feed. The nurse determines that the client's understanding of breast-feeding instructions is sufficient when she states:
"Breast-feeding will assist in lowering maternal blood glucose"
The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client states which of the following?
"I can have epidural as soon as I start contracting"
An antenatal G2, T1, P0, Ab0, L1 client is discussing her postpartum plans for birth control with her health care provider. In analyzing the available choices, which of the following factors has the greatest impact on her birth control options?
Breast- or Bottle-feeding plan
Which of the following observation is expected when the nurse is assessing the gestational age of a neonate born at term?
Sole creases covering the entire food
a client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. after unprotected intercourse, the client calls the clinic to ask about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of following response?
"I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy,"
A nurse is discussing discharge instructions with a client. Which of the following statements indicate that the client understands the resources and information available if needed after discharge?
"I have the hospital phone number if I have an question"; "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance"; "I know if i get fever or chills or change in lochia to call the physician"; "I will continue my prenatal vitamins until my postpartum checkup or longer"
A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she makes which statement?
"I have this disease because I don't eat enough food with iron"
After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
"I should drink at least five glasses of fluid daily"
After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which of the following client statements indicates a need for further teaching?
"If I gain or lose 20 lb (9.1 kg), I can still use the same diaphragm"
After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful?
"If there is discharge from my nipples, I should call my health care provider"
Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which of the following statements by the infant's mother indicates understanding of the disease and its management?
"My baby can't have milk-based formula"; "We have to follow a strict phenylalanine diet"; "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow"
A 39-year-old multigravida client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client statements indicates effective teaching?
"My fallopian tubes will be tied off through a small abdominal incision"
After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective?
"Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy."
A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal birth. Which of the following responses would be most helpful?
"What is it that concerns you about pregnancy, labor, and childbirth?
The nurse is reviewing discharge instructions with a postpartum breast-feeding client who is going home. She has chosen medroxyprogesterone (Depo-Provera) as birth control. Which statement by the client identifies that she needs further instruction concerning birth control?
"You will give me my first Depo-Provera shot before I leave today"
As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last?
*Call for immediate assistance; *Assess for ruptured membranes; *Turn the client to her side; *Maintain airway
A client with pregnancy induced hypertension is to receive magnesium sulfate to run at 3 g/h with normal saline to maintain the total IV rate at 125 mL/h. The nurse giving end of shift report stated that the client's blood pressures have been elevated during the night. The oncoming nurse checked the client and found magnesium sulfate running at 2 g/h. Identify the nursing actions to be taken from first to last.
*Correct the IV rates; *Assess the client's current status; *Notify the primary health care provider of the incident; *Initiate an incident report
The nurse notices that a client who has just given birth is short of breath, ashen in color, and begins to cough. She becomes limp on the birthing table. At last assessment 1/2 hour ago, her temperature was 98 (36.7), pulse 78, respirations 16. Determine the nursing actions in the order the should occur.
*Establish unresponsiveness, *Ask staff to activate emergency response system *Begin compression *Open airway using head tilt-chin lift *Give breaths
After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the following time spans?
12 months
A new mother asks, "When will the soft spot near the front of my baby's head close? The nurse should tell the mother the soft spot will close in about:
12 to 18 months
While assisting a primiparous client with her first breast-feeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple?
Brush the neonate's lips lightly with the nipple
A breast-feeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following?
Fat
A client has just had a cesarean section for a prolapsed cord. In reviewing the client's history, which of the following factors places a client at risk for cord prolapse?
2 station, low birth weight infant, rupture of membranes, breech presentation
The nurse is receiving shift report on four clients on an antenatal unit. The four clients are: (1) a 35-week-gestation mother with severe pre-eclampsia started on a maintenance dose of magnesium sulfate 1 hour ago; (2) a 30-week-gestation patient with preterm labor on oral nifedipine and having no contractions in 6 hours (3) a hyperemesis client with emesis four times in the past 12 hours; and (4) a 33-week-gestation client with placenta previa who began to feel pelvic pressure during change of shift report. In what order should the nurse see these clients?
3, 1, 4, 2
A 6-lb, 8-oz (2,948 g) neonate was born vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, and overall pale white in color. The apgar score is:
4
At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. The nurse interprets these findings as indicating that this neonate is most likely experiencing which of the following?
A state of deep sleep
The nurse is planning care for a group of pregnant clients. Which of the following clients should be referred to a health care provider immediately?
A woman at 32 weeks' gestation and is preeclamptic with +3 proteinuria
Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?
A client at 32 weeks' gestation who has preeclampsia and +3 proteinuria who is returning for evaluation of epigastric pain
The primary health care provider determines that the fetus of a multiparous client in active labor is in distress, necessitating a cesarean birth with general anesthesia. Before the cesarean birth, the anesthesiologist prescribes cimetidine (Tagament) 300 mg PO. After administering the drug, the nurse should assess the client for reduction in which of the following?
Acid level of the stomach contents
After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction?
Brain damage may occur if the molding doesn't resolve quickly
Shortly after birth, the nurse measures the circumference of a term neonate's head and chest. When the two measurements are compared, which of the following would the nurse expect to find about the head circumference?
Approximately 2 cm larger than the chest
A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan?
As ovulation approaches, cervical mucus is abundant and clear
The nurse and a nursing assistant are caring for clients in a birthing center. Which of the following tasks should the nurse delegate to the nursing assistant?
Assisting an active labor client with breathing and relaxation; Ambulating a post cesarean client to the bathroom
A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which of the following signs and symptoms?
Bleeding that is concealed or apparent; Abdominal rigidity; Painful abdomen
A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result?
Bradycardia
When reviewing the prenatal history for a newly born neonate, the nurse notes that the mother has neurofibromatosis. The nurse should further assess the neonate for:
Cafe au lait spots
A client has experienced a postpartum hemorrhage. The primary health care provider verbally ordered carboprost tromethamine (Hemabate) 0.25 mg IM stat at the time of the hemorrhage and this was given by the nurse. The primary health care provider put a prescription into the electronic medical record for 0.25 mg carboprost tromethamine IV stat. When seeing the prescription, how should the nurse administering the carbboprost tromethamine respond?
Call the primary health care provider, discuss the prescription, and request revision if heard correctly
After vaginal birth of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the primary health care provider based on the analysis that his may be indicative of which anomalies?term-40
Cardiovascular anomalies
The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains?
G3, P3 client who is breast-feeding her infant
When preparing a multigravid client who has undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow-up care. The nurse determines that the client understands the instruction when she says that she is at risk for developing which of the following?
Choriocarcinoma
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?
Client at 38 weeks' gestation with active herpes lesions
A client is admitted at 30 weeks' gestation with contractions every 3 minutes. Her cervix is 1 to 2 cm dilated and 75% effaced. Following a 4-g bolus dose, IV magnesium sulfate is infusing at 2 g/h. How will the nurse know the medication is having the intended effect?
Contractions will decrease in frequency, intensity, and duration
A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, the nurse determines that an appropriate outcome for the couple would be to accomplish which of the following by the end of this visit?
Describe each of the potential causes and possible treatment modalities
Which of the following would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?
Diaphragms should not be used if the client develops acute cervicitis
A full-term client is admitted for induction of labor. When admitted, her cervix is 25/0. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction?
Dinoprostone
A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?
Document fetal well-being
Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next?
Encourage the client to ambulate to the bathroom and void
While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the primary health care provider?
Expiratory grunt
After a dilatation and curettage (D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which of the following would be most important?
Hemorrhage
A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the primary health care provider with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure?
Hold the neonate steady in the correct position; Ensure a patent airway; Maintain a sterile field
Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following?
Hypertension
A client is scheduled to have in vitro fertilization (IVF) as an infertility treatment. Which of the following client statements about IVF indicates that the client understands this procedure?
IVF involves bypassing the blocked or absent fallopian tubes
A full-term neonate is admitted to the noraml newborn nursery. The nurse notes a Moro reflex. What should the nurse do next?
Identify this reflex as a normal finding
A breast-feeding primiparous client with a midline episiotomy is prescribed ibuprofen (Motrin) 200 mg orally. The nurse instructs the client to take the medication:
Immediately after a feeding
A 22-year-old client tells the nurse that she and her husband are trying to conceive a baby. When teaching the client about reducing the incidence of neural tube defects, the nurse would emphasize the need for increasing the intake of which of the following foods?
Leafy green vegetables; Strawberries; Beans; Sunflower seeds; Lentils
The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which of the following?
Maintain the integrity of practice and shape social policy; Develop, maintain, and improve health care environments; Be responsible and accountable for individual practice; Increase professional competence and personal growth
The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which of the following positions?
Side-Lying
Which of the following forms the basis for the teaching plan about avoiding medication use unless prescribed for a primiparous client who is breast-feeding?
Medications may be excreted in breast milk to the nursing neonate
The nurse is caring for a primipara who gave birth yesterday and has chosen to breast-feed her neonate. Which assessment finding is considered unusual for the client at this point postpartum?
Milk Production
A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which of the following would the nurse include when teaching the mother about neonatal strabismus?
Neonates commonly lack eye muscle coordination
A primiparous client, 48 hours after a vaginal births, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following?
Orange juice
The nurse is assessing the perineal changes of a multigravid client in the second stage of labor. The illustration below represents which of the following perineal changes?
Oval opening
After instructing a 20-year-old nulligravid client about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which of the following as an adverse effect?
Ovarian Cancer
A full-term client is admitted for an induction of labor. The health care provider has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client?
Oxytocin 30 units in 500 mL D5W
A primiparous client who is beginning to breast-feed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with:
Passive immunity from maternal antibodies
A nurse and an LPN are working in the labor and birth unit. Of the following assessments and interventions that must be done immediately, which should the nurse assign to the LPN?
Perform a straight catheterization for protein analysis
The nurse is caring for a full-term primiparous client who is in the transition stage of labor. The client is writhing in pain and asking "help me, help!" The epidural redose was 3/4 hour ago, and she was catheterized just prior to the epidural redose. Her last vaginal exam 1 hour ago showed that she was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client?
Perform a vaginal exam to determine if the client is fully dilated
The triage nurse is giving a telephone report to the receiving nurse in the labor and birth unit. The client is a G4 P3 who is 8 cm dilated and is being transferred to the labor and birth unit. How should the labor and birth nurse manage the next ten minutes with the client?
Place client on the fetal and contraction monitor; Call other staff to set up the birthing table; Assess comfort needs of client; Determine support systems for client
A laboring client at -2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
Place gentle pressure upward on the fetal head
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn
Places the infant horizontally and in a prone position with one hand
A client at 4 weeks postpartum tells the nurse the that she can't cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she dose not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider because the mother should be evaluated further for:
Postpartum depression
A multigravid client is in active labor with twins at 38 weeks' gestation. The nurse should monitor the client closely for symptoms of which of the following?
Preeclampsia
As a nurse begins her shift on the obstetrical unit, there are several new admissions. The client with which of the following conditions would be a candidate for induction?
Preeclampsia
A breast-feeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client has a warm, red, painful breast; a temperature of 100F (37.7C); and flulike symptoms. What should the nurse do?
Refer the woman to her primary health care provider
The nurse is caring for a multiparous client after vaginal birth of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to:
Relate to each twin individually to enhance the attachment process
After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
Release of oxytocin during the breast-feeding session
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?
Remain in a side-lying position with the head elevated
A nurse and a nursing assistant are caring for clients in a labor and birth unit. Which task should the registered nurse assign to the nursing assistant?
Remove a fetal monitor and assist a client to the bathroom
A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include:
Reposition patient, apply oxygen, and increase IV fluids
Assessment of a term neonate at 2 hours after birth reveals a heart rate of less than 100 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifies the primary health care provider based on the interpretation that these findings may lead to which condition?
Respiratory Arrest
A woman who is Rh-negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho(D) Immune Globulin (RhoGAM). The nurse determines that the client understands the purpose of RhoGAM when she states:
RhoGAM will prevent antibody formation in my blood
A woman who has given birth to a health neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider about:
Saturating a pad in an hour
A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires the use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following?
Take her temperature at the same time every morning before getting out of bed
A laboring client smiles pleasantly at the nurse when asking simple questions. The client speaks only Mandarin and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching birth?
The fetal monitor strip shows early decelerations
A client at 33 weeks' gestation is admitted in preterm labor. She is given betamethasone 12 mg IM every 23 hours x 2. What is the expected outcome of this drug therapy?
The neonate will be born with mature lungs
The health care provider has performed an amniotomy on a laboring client. Which of the following details must be included in the documentation of this procedure?
Time of rupture; Color and clarity of fluid; Fetal heart rate (FHR) and pattern before and after the procedure; Odor and amount of fluid
Which of the following assessment findings in a term neonate would cause the nurse to notify the primary health care provider?
Unequally sized corneas
A 22-year-old nulligravid client tells the nurse that she and her husband have been considering using condoms for family planning. Which of the following instructions should the nurse include about the use of condoms as a method for family planning?
Using a spermicide with the condom offers added protection against pregnancy
A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. which of the following would the nurse include in the teaching plan?
cervical mucus is carefully monitored for changes
During a home visit, a breast-feeding client asks the nurse what contraception method she and her husband should use until she has her 6-weeks postpartal examination. Which of the following would be most appropriate for the nurse to suggest?
condom with spermicide
A 1-day-old breast-fed infant has a bilirubin level that is at an intermediate risk for jaundice. Which statement by the infant's mother indicates an understanding of the teaching regarding jaundice?
i should breast-feed my baby as often as possible
Which of the following would be important to include in the teaching plan for the client who wants more information on ovulation and fertility management?
ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle
While performing a physical assessment on a term neonate shortly after birth, which of the following would cause the nurse to notify the primary health care provider?
single crease on each of the palms
After the birth of a neonate, a quick assessment is completed. The neonates is found to be apneic. After quickly dying and positioning the neonate, what should the nurse do next?
start postive pressure ventilation
which of the following instructions about activities during menstruations would the nurse include when counseling an adolescent who has just begun to menstrual?
take a mild analgesic if needed for menstrual pain
A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds based on the understanding about which of the following?
the mother can bring the daughter any foods that she desires
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring ever 1 1/2 minutes. The uterine resting tone is greater than 20 mm mercury with an abnormal fetal heart rate and pattern. Which of the following actions should the nurse take first?
turn off the oxytocin infusion
After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instruction when she describes the tonic neck reflex as occurring when the neonate does which of the following?
turns head to the left, extends left extremities, and flexes right extremities
