HESI PRACTICE FOCUS
A normal finding
A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. This nurse interprets this assessment data in which way?
In 2 to 4 weeks
A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity at which time?
Check her blood glucose level.
A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. Which is the appropriate response?
"I need to stay in bed for the rest of my pregnancy
A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction?
History of IV drug use
A clinic nurse is following a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care?
Increased shortness of breath and bilateral crackles in the lungs
A clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up?
Supine with a wedge under the right hip
A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client in which way?
Eat carbohydrates such as cereals, rice, and pasta
A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to take which action?
Document the finding
A licensed practical nurse (LPN) is assisting the registered nurse (RN) in assessing a pregnant client's deep tendon reflexes and a reflex of 2+ is noted. Based on this finding, the LPN anticipates that the RN will take which action?
Altered tissue perfusion related to hypotensive syndrome (vena cava syndrome)
A nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, "I think my wife is going into shock or something! She was just lying there, and then she turned so pale, and her hands are so clammy. She said she was dizzy and sick to her stomach." The nurse notes on the noninvasive blood pressure monitor that the woman's pulse is 58 beats/min and her blood pressure is 90/50 mm Hg. The nurse interprets these findings as indications that the woman is experiencing which situation?
A rubella vaccine must be administered after childbirth.
A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse provides the client with which information?
Administers oxygen to the woman
A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately takes which action?
Uterine tender to palpation
Placental abruption is suspected in a client who is experiencing vaginal bleeding. Which finding would the nurse expect to note?
Apply oil to the affected area on the infant's scalp
nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to take which action?
These contractions are a common occurrence of pregnancy
A nurse reinforcing teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse provides the client with which information about these contractions?
T-lymphocyte determination
A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the health care provider will prescribe?
Contacting the health care provider
A nurse caring for a client in labor assists with data collection. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, which is the appropriate nursing action?
Providing pain relief
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client?
Lima beans
A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid?
Performing a sudden tap on the cervix
A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement?
"Do you have sharp pain on the right or left side of your pelvis?"
A nurse is assisting with data collection of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder?
The mother may need to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months. Correct
A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, reinforcing instructions to the mother regarding therapeutic management of the disease, provides the mother with which information?
A copper-colored rash
A nurse is conducting a home visit with a mother and her 1-week-old infant, who is at risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant?
Prone
A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant?
Apple and whole-grain toast
A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat?
he newborn does have a risk of contracting the infection."
A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. Which is the appropriate response?
Instructs the client to take several deep breaths
A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse first takes which action?
Reporting the time of last food intake to the health care provider
A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100°F, and the client reports that she last ate 2 hours ago. The client also states that "everything happened so fast" and that she has had no preparation for the cesarean delivery. Which actions should the nurse take first?
Documenting the findings
A licensed practical nurse (LPN) is changing the diaper of a 1-day-old full-term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that which is the appropriate action
Strong-smelling amniotic fluid
A licensed practical nurse (LPN) is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the LPN to contact the registered nurse?
Diaphoresis and tachycardia
A licensed practical nurse (LPN) is monitoring a client in the third trimester of pregnancy who is at risk of developing disseminated intravascular coagulation (DIC). Which finding would prompt the LPN to contact the registered nurse?
Documenting the finding
A licensed practical nurse (LPN) is monitoring a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the LPN take in response to this observation?
Assist in repositioning the uterus through the vagina into a normal position
After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to take which action?
Is adjusting well to extrauterine life
After the delivery of a newborn, a nurse determines that the Apgar score is 8. The nurse interprets this score in which way regarding the infant?
14 to 16 weeks of gestation
A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as which stage of gestation?
Fetal bradycardia Correct Maternal tachypnea Correct Maternal complaint of sudden sharp abdominal pain
A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture? Select all that apply
Neonatal abstinence syndrome
A neonate is irritable, cries incessantly, and has a temperature of 99.4°F. The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with which disorder?
Anxiety and the need for support
A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as most likely the result of which situation
Concern about her own and the baby's well-being
A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin (Pitocin) stimulation. The nurse determines that the client's behavior may be a result of which situation?
Hemorrhage
A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for which complication?
Pressure on the fetal head during a contraction
A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which situation would the nurse suspect in light of this observation?
Increased fibrin degradation products
A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which laboratory finding causes the nurse to suspect DIC?
Encourage the intake of oral fluids
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38°C (100.4°F). Which is the most appropriate nursing action? A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38°C (100.4°F). Which is the most appropriate nursing action?
Electronic Doppler
A nurse is preparing to count the fetal heartbeat in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse use to assess the fetal heartbeat?
Ask the client to empty her bladder
A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first take which action?
Drinking fewer than four glasses of fluid daily
A nurse is reviewing the medical record of a pregnant client with sickle cell anemia. To which information related by the client would the nurse give the highest priority?
At zero station
A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is in which location?
