HESI A2: MOBILITY PREP

A client is admitted to the birthing center in active labor. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor does the nurse identify? 1. First 2. Latent 3. Second 4. Transitional

First- the first stage of labor lasts until the cervix is fully dilated @10cm. The second stage lasts from full dilation to birth.

A client is admitted with a diagnosis of stage 0 cervical cancer (carcinoma in situ). What does the nurse emphasize while helping the client understand her diagnosis and prognosis? 1. Five year survival rates for this cancer are nearly 100% with early treatment 2. Radiation therapy is as successful as surgery in the treatment of this type of cancer 3. Cancer has probably extended into the vaginal wall and may require a radical hysterectomy. 4. Stage 0 indicates that the cancer is invasive and may require surgery in addition to radiation therapy.

Five year survival rates for this cancer are nearly 100% with early treatment. There is no distinct tumor, just rapidly dividing neoplastic cells; stage 0 is preinvasive.

While experiencing contractions every 2 to 3 minutes lasting from 60 to 90 seconds, a client complains of severe rectal pressure. What should the nurse's priority intervention be at this time? 1. Assess the fetal heart rate for change 2. Inspect the client's perineum for bulging 3. Determine when the client's labor began 4. Verify whether the membranes have ruptured

Inspect the client's perineum for bulging; while all signs indicate impending birth, the perineum should be inspected for evidence of caput.

A newborn who is born at 36 weeks' gestation weighs 8 lb 13 oz (3997 g). How should the nurse document this finding? 1. LGA and Term 2. LGA and Preterm 3. AGA and Term 4. AGA and Preterm

LGA and preterm. Less than 37 weeks = preterm and expected weight at 36 weeks is between 4lb 3oz and 7lb 1oz

What should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder? 1. Maintaining sterility of the exposed bladder 2. Measuring output from the exposed bladder 3. Protecting the skin surrounding the exposed bladder 4. Applying a pressure dressing to the exposed bladder

Protecting the skin surrounding the exposed bladder. Constant drainage of the skin promotes excoration and infection so the skin must be protected. Sterility is impossible to maintain due to the leakage of urine. Output will be difficult to measure due to constant leakage of urine. A pressure dressing is contraindicated because it will traumatize the exposed bladder.

A nurse administers two serial intramuscular injections of betamethasone to a woman at 32 weeks gestation who has been admitted in preterm labor. The nurse knows that this medication is given to accomplish what purpose? 1. Stop the process of labor 2. Increase placental perfusion 3. Stimulate surfactant production 4. Reduce intensity of contractions

Stimulate surfactant production because betamethasone is a corticosteroid.

A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea throughout the day. Which interventions should the nurse recommend? Select all that apply. 1. Focus on and repeat a rhythmic chant 2. Sit upright for 30 mins after meals 3. Take low-sodium antacids after meals 4. Drink carbonated beverages with meals 5. Eat small, frequent meals and eat dry crackers in between

1 & 5 (Focus on and repeat a rhythmic chant and Eat small, frequent meals and eat dry crackers in between). Focusing helps mitigate odors, tastes, and thoughts that may cause nausea. Avoiding an empty stomach decreases the occurrence of nausea associated with pregnancy. Sitting upright and taking antacids will prevent heartburn but not nausea.

A newborn's mother is being treated with clemastine while breast-feeding. Which physiologic factors alter the pharmacokinetic properties of this drug in the neonate? Select all that apply. 1. Decreased fat content 2. Increased protein binding 3. Immature blood-brain barrier 4. Increased first pass elimination 5. Decreased GFR

1, 3, & 5 (Decreased fat content, Immature blood-brain barrier, and Decreased GFR). In neonates, fat content is low due to a large amount of total body water. As a result, the drug readily enters the brain due to the immature blood-brain barrier. Neonates have immature kidneys which means a decreased GFR.

Women who become pregnant for the first time at a later reproductive age (35 years or older) are at risk for what complications? Select all that apply. 1. Seizures 2. Preterm Labor 3. Multiple Gestation 4. Chromosomal Anomalies 5. Bleeding in the first trimester

2, 3, 4, & 5 (Preterm Labor, Multiple Gestation, Chromosomal Anomalies, and Bleeding in the first trimester). Risk for preterm labor is age associated to older primigravidas & adolescents. Mature women have increased incidence of multiple gestation due to fertility drug use/in vitro fertilization. After age 35, women have an increased risk of birthing babies with chromosomal anomalies and in the first trimester, bleeding may occur as a result of spontaneous abortion.

A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is a recent immigrant from Asia, and the nurse explores the foods that the client usually eats. Which foods should the nurse counsel the client to avoid during pregnancy? Select all that apply. 1. Yogurt 2. Oily Fish 3. Apricots 4. Raw Shellfish 5. Herbal Supplements 6. Soft-scrambled Eggs

4, 5, & 6 (Raw Shellfish, Herbal Supplements, and Soft-scrambled Eggs)

When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with his or her own feelings about abortion, death, and loss so that he or she may do what? 1. Maintain control of the situation 2. Share personal grief with the clients 3. Allow the clients to express their greif 4. Teach the clients how to cope effectively

Allow the clients to express their grief. The nurse can be more sensitive to the client's needs by addressing their emotions first. A time of crisis is not a time to teach; the client is not ready to learn.

A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next? 1. Changing the client's position 2. Taking the client's blood pressure 3. Stopping the client's oxytocin infusion 4. Preparing the client for an immediate birth

Changing the client's position because decels are usually the result of cord compression; a change in position will relieve the pressure on the cord.

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? 1. Gravids 3 with twins 2. Gravida 5 with endometreosis 3. Gravida 2 who had a 9lb baby boy 4. Gravida 1 who has had an intrauterine fetal death

Gravida 1 who has had an intrauterine fetal death; intrauterine fetal death is a risk factor for DIC as well as abruptio placentae, amniotic fluid embolism, sepsis, and liver disease.

A client has undergone suction curettage for the removal of a hydatidiform mole. What should the nurse emphasize when planning for the client's discharge? 1. The necessity of at least 6 weeks of F/U care 2. The reasons for postponing another pregnancy for an entire year 3. The risk factors for the development of another hydatidiform mole 4. The basis for chemotherapy if the chronic gonadotropin hormone level falls slowly

The reasons for postponing another pregnancy for an entire year. The pt's hCG will be checked biweekly until it returns to the expected range and stays there for 3 weeks. Monthly measurements are taken for as long as 6 months and then bimonthly for the rest of the year. If measurements remain within the expected range, another pregnancy may be attempted. F/U care should last for at least 12 months, IDing risk factors for another mole is not priority, Chemo only given if hCG increases, not decreases.

(Maternity)The nurse examines a client who has had a cesarean birth. It has been 3 days since the birth, and the client is about to be discharged. Where does the nurse expect the fundus to be located? 1. 1 fingerbreadth below the umbilicus 2. 2 fingerbreadths below the umbilicus 3. 3 fingerbreadths below the umbilicus 4. 4 fungerbreadths below the umbilicus

Three fingerbreadths below the umbilicus- the fundus descends one fingerbreadth per day from first postpartum day.

During her first visit to the prenatal clinic a client is found to be obese. During the ensuing 5 months, the client has been unsuccessful in adhering to her nutritional plan. Which finding indicates to the nurse that the client has been successful during the sixth month? 1. Weight loss of 1lb 2. Weight gain of 2lb 3. No weight change from the last month 4. The client's statement that she lost weight last week

Weight gain of 2lb because the client needs to gain some weight to meet the fetus' nutritional needs and 2lb of weight gain is appropriate. Weight loss is contraindicated in pregnancy because it may interfere with fetal G&D