Maternity HESI

The nurse is checking a clients record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse would note?

1. Ballottement 2. Chadwicks sign 3. Uterine enlargment 4. Braxton Hicks contractions

A newborn has just been circumsized and is being discharged home in 2 hours. Which instructions need to be provided by the nurse to the parents? SATA

1. Do not wash the penis with soap until the circumcision is healed. Which takes 5 to 6 days. 2. Change the diaper every 4 hours or more often to inspect the penis for drainage or infection. 3. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.

The nurse is assisting in monitoring a client in preterm labor who is receiving IV magnesium sulfate. The nurse would monitor for which adverse affects of this medication?

1. Flushing 2. Depressed respirations 3. Extreme muscle weakness

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures need to be implemented? Select all that apply

1. Monitor the skin temperature closely 2. Reposition the newborn every 2 hours 3. Cover the newborns eyes with shields or patches

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student needs further teaching if which responses are made?

1. Prevents large particles such as bacteria from passing to the fetus. 2. Provides an exchange of nutrients and waste products between the mother and the fetus.

A pregnant client is receiving magnesium sulfate for the management of pre-eclampsia. The nurse who is assisting in caring for the client determines that the client is experiencing toxicity from the medication if which findings are noted during assessment?

1. Respirations of 10 breaths per minute 2. Urine output of 20 ml in an hour.

The nurse is preparing a list of self care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions would be included on the list? Select all the apply.

1. Rest during the acute phase 2. Wear a supportive, no underwire bra. 3. Maintain a fluid intake of at least 3000 ml 4. Continue to breast feed if the breast are not too sore.

The nurse working in a prenatal clinic reviews chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plan care understanding that which findings are charecteristic of this type of pelvis?

1. Round Shape 2. Diagnanole conjucant meaures 12.5 to 13 cm 3. Blunt somewhat widely seperated ischial spines

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings would indicate to the nurse that the oxytocin infusion needs to be immediatly discontinued?

1. Uterine hyperstimulation 2. Late decelerations of the fetal heart rate.

During a prenatal visit the nurse checks the fetal heartrate of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?

150 beats per minute

Nagele's Rule

1st day of last period + 7 days - 3 months

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which of the following indicates that the placenta has seperated?

A change in the uterine contour

The perinatal client is admitted to the obstetrical unit during the exacerbation of a heart condition. When planning for the nutritional requirements of the client the nurse would consult with the dietician to ensure which dietary measure?

A diet that is high in fluids and fiber to decrease constipation.

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse would tell the mother that whihc is a sign of infection?

A moist cord with discharge

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the primary health care provider has documented the prescence of Goodells sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy.

A softening of the cervix

The nurse notes hypotonia, irritability and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign is consistent with FAS?

Abnormal palmar creases

The nurse suspects the client has a pumlonary embolism. Which is the most important nursing action?

Administer oxygen by face mask as prescribed.

The nurse is assigned to care for a client after a c-section. To prevent thrombophlebitis, the nurse would encourage the woman to take which priority action?

Ambulate frequently

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus would the nurse expect to note?

At the level of the umbilicus

The nurse is assigned to care for a client who is in early labor. When collecting data from the client which would the nurse check first?

Baseline fetal heart rate

The nurse is reinforcing measures regarding the care of the newborn with a mother. The bathe the newborn, the mother would be taught which intervention?

Begin with the eyes and the face.

RHo (D) immune globuline is prescribed for a client after delivery and the nurse assisting in caring for the client provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?

Being affected by RH incompatibility

A client in preterm labor (31 weeks) who is dilated to 4cm has been started on magnesium sulfate and her contractions have stopped. If the clients labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication?

Betamethasone

The nurse is assisting in caring for a post term neo nate immediately after admission to the nursery. The priority nursing action would be to monitor which clinical parameter?

Blood glucose levels

Methylergonovine is prescribed for a woman to treat postpartum hemmorhage. Before administration of methylergonovine, what is the priority nursing assessment.

Blood pressure

Chadwick's sign

Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion.

Chadwicks sign

Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion. Occurs about week 4.

The nurse notes that the 4 hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action?

Check the vital signs

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from pre-eclampsia to eclampsia the nurse would take which action first?

Clear and maintain an open airway

The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks gestation with Apgar scores of 1 and 4. When planning for the admission of this infant which is the nurses highest priority?

Connecting the resuscitation bag to the oxygen outlet.

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The Instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?

Connects the umbilical vein to the inferior vena cava.

A primigravidas membranes rupture spontaneously, which action must the nurse take first?

Determine the fetal heart rate.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action would the nurse take initially?

Determine the maternal vital signs and fetal heart rate

A couple comes to the family planning clinic and asks about sterilizations procedures. Which question by the nurse helps determine whether this method of family planning is appropriate?

Do you plan to have any other children?

The nurse is reinforcing instructions to a pregnant client regarding measurs to prevent heartburn. The nurse would instruct the client to take which best measure?

Drink decaffeinated coffee and tea.

After birth the nurse prevents hypothermia as a result of evaporation by performing which action?

Drying the baby with a warm blanket.

The pregnant client tells the nurse that she is experiencing morning sickness. What information would the nurse provide to the client to assist with relief?

Eating dry crackers before arising, avoid brushing teeth immediately after arising, eating small frequent low fat meals during the day, drinking liquids between meals rather than at meals, avoiding fried foods and spicy foods, ask the PCP about accupressure. Ask about the use of herbal remedies.

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicated an abnormal physical finding that necessitates further testing?

Fetal heart rate of 180 beats per minute. Normal is 139-151 during the second trimester.

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5 year old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document which as the GTPAL for this client?

G = 2, T=1, P=0, A=0, L=1

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3 year old child who was born at 39 weeks gestation. The nurse would document which gravida and para status on this client?

Gravida II, Para I

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breast feeding when she makes which statement?

I dont need to take birth control because I will be breast feeding.

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed?

I will flush the eyes after instilling the ointment

The nurse is assisting in caring for a premature infant who needs to receive beractant for respiratory distress syndrome. The nurse plans to assist in adminitering the medication by which route?

Intratracheal

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

It is the fetal movement that is felt by the mother.

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2023. Using Naegels rule, the nurse determines the estimated date of birth is which date.

July 27, 2024

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psycho social needs of the client, the nurse would plan which action?

Keep the client and her family members informed of her progress.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9cm dialated and is experienceing precipitous labor. What is the priority nursing action?

Keep the client in a side lying position

The nurse is assigned to assist with caring for a neonate born to a mother who is HIV positive. The nurse understands that which of these need to be included in the plan of care?

Maintain standard precautions at all times while caring for the neonate.

Types of abruptio placenta

Marginal abruption with external bleeding, partial abruption with concealed bleeding and complete abruption with concealed bleeding.

The three classifications of placenta previa

Marginal, this is where the placenta slightly covers the cervix. Partial, this is when the placenta covers and fairly good amount of the cervix but not all. Total, this is where the placenta completely covers the cervix.

A mother is breast feeding her newborn baby and experiences breast engorgement. The nurse would encourage the mother to do which to provide relief of the engorgement?

Massage the breast before feeding to stimulate letdown.

An opiod analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medicaiton is readily available if respiratory depression occurs?

Naloxone

A client asks the nurse why her newborn baby needs an injection of Vitamin K (phytonadione). The nurse would make which statement to the client?

Newborns are deficient in vitamin K. This injections prevents your baby from abnormal bleeding.

The nurse is caring for a postpartum client. At 4 hours postpartum, the clients temperature is 102F (38.9) celsius. Which is the appropriate nursing action?

Notify the Registered Nurse who will then contact the primary health care provider.

A woman in active labor has contractions every 2-3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 bpm. On the basis of these findings which is the priority nursing action?

Notify the registered nurse immediately

Methylergonvine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse consults with the registered nurse about contacting the primary health care provider who prescribed the medication if which condition is documented in the clients medical history?

Peripheral vascular disease

The nurse caring for a client with abruptio placentae is monitoring the client for signs of dissiminated intravascular coagulopathy (DIC). The nurse would suspect DIC if which is observed?

Petechia oozing from injection sites and hematuria.

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse would perform which action?

Prepare an ice pack for application to the area

The client received epidural anethesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours pospartum the clients systolic bp dropped 20 points, the diastolic bp dropped 10 points and her pulse is 120 bpm. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis the nurse needs to plan which action?

Prepare the client for surgery

The nurse administers erythromycin oitment (0.5%) to the newborns eyes and the mother asks the nurse why this is done? The nurse would give which response to the client?

Prevents opthalmia neonatorum born to a woman with an untreated gonococcal infection.

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?

Provides an exchange of nutrients and waste products between the mother and the fetus.

precipitous

Rapid delivery

The nurse palpates the fundus and checks the character of the locia of a postpartum cient who is in the 4th stage of labor. What locia charecteristic would the nurse expect to note?

Red

The nurse is caring for a client who is in labor. The nurse rechecks the clients blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse would encourage the client to remain in what position?

Side lying

The client who is being prepared for cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus the nurse would place the client in which position?

Supine with a wedge under the right hip

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse would do which to help the woman processs what has happened.

Support the mother in her reaction to the newborn.

The nurse would monitor for which signs associated with repiratory distress syndrome in a preterm newborn?

Tachypnea and retractions

The client is undergoing amniocentesis at 16 weeks gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions would the nurse reinforce to the client?

The bladder must be full during the examination. The bladder must be kept full before 20 weeks gestation to support the weight of the uterus.

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination would the nurse make?

The bright red bleeding is abnormal and needs to be reported

The nurse is monitoring a client with mild gestational hypertension (GH). Which data indicated that GH is a concern?

The client complains of a headache and blurred vision.

Leopolds maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information would the nurse provide to the client about Leopolds maneuvers?

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

A client is in active labor. The nurse is monitoring the fetal heart rate and notes that the heart rate is 180 BPM lasint for longer than 10 minutes. What would the nurse do?

The normal fetal HR is 110-160 BPM. If fetal tachycardia or bradycardia occurs the nurse must change the position of the mother. administer oxygen and check the mother's vital signs including temperature. In addition, the nurse would notify the RN immediately so that further assessment can be done regarding the cause of the tachycardia. The primary health care provider is also notified.

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means? Which description would the nurse give to the client?

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

Ballottement

The rebounding of a fetus against the examiners fingers.

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure?

The uterus weighs about 2 ounces

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse needs to tell the client that fetal circulation consists of which components?

Two unbilical arteries and one unbilical vein.

Veal Chop

V- Variable C- Cord Compression E- Early Decels H- Head Compression A- Accelerations O - OK L-Late Decels P - Placenta

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse would initially check which item?

Vital signs

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse would make?

Where fertilization occurs

Dissiminated Intravascular Coagulation (DIC)

abnormal coagulation involving fibrinogen

primigravida

first pregnancy

GTPAL

gravida, term births, preterm births, abortions, living children

gestational hypertension

high blood pressure during pregnancy

condyloma acuminatum

lesion that appears as a result of human papilloma virus; on the skin, lesions appear as cauliflower-like warts, and on mucous membranes, they have a flat appearance; also known as venereal or genital warts

Goodells sign

softening of the cervix

Hegars sign

softening of the lower uterine segment

Holman's sign

this sign is positive when passive dorsiflexion of the ankle by the examiner elicits sharp pain in the calf