HESI V2

A client at 31 weeks gestation with a fundal height measurement of 25 c is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide.

Evaluation of fetal growth.

A care provider prescribes a maintenance dose of magnesium sulfate 2 grams per hour intravenously for clients with preeclampsia. The IV bag contains magnesium sulfate 20 grams how much in ml/Hr. should a nurse program the infusion pump enter numerical value only.

100 ml

A primigravida client in labor is receiving oxytocin 4 mu/minute to help promote an effective contraction pattern. The available solution is lactated ringer's 1,000 ml with oxytocin 20 units. The nurse should program the machine to deliver how many ML per hour.

12 mL

The nurse is planning discharge teaching for four mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?

A primiparous woman who has recently migrated to the US with a spouse.

A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. which assessment finding warrants immediate intervention by the nurse?

Absent Patellar reflexes

A primiparous woman presents in labor with the following labs. hemoglobin 10.9 g/dl (109 g/dl) Hematocrit 29% (0.29) hepatitis surface antigen positive, Group B Streptococcus positive and rubella non-immune. which intervention should the nurse implement?

Administer ampicillin 2 grams intravenously.

What should be the primary focus of nursing care in the transitional phase of Labor for a client who anticipates an unmedicated delivery.

Assessing the strength of uterine contractions

The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor which maternity description is most important in preventing this fetus from developing respiratory distress syndrome.

Betamethasone 12 mg deep IM

The nurse places one hand above the symphysis while massaging the fundus of a multiparous client who's uterine tone is boggy 15 minutes after delivering a 7 pounds 10 ounces 3220 grams infant which information should the nurse try to provide the client about those finding.

Both the lower uterine segment and the fundus must be massaged

A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first?

Call the HCP

A newborns head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 centimeters). The nurse notes that this infant has no molding, and it was a bridge presentation delivered by cesarean section. What action should the nurse take based on this data.

Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.

The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse documents in the medical record?

Cephalhematoma

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. which action should the nurse implement first.

Change the client's position

A client in the first trimester of pregnancy calls the prenatal clinic to report she's nauseated, and her stools are black and thick since she started taking iron supplements last week. How should the nurse respond? select all that applies.

Changes in color and consistency of stool are normal.

A new mother who is a lacto-ovo vegetarian plans to breast feed her infant. which information should the nurse provide prior to discharge.

Continue prenatal vitamins with B12 While breastfeeding

Following a traumatic delivery an infant receives an initial Apgar score of 3. which intervention is most important for the nurse to implement.

Continue resuscitative efforts

A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take.

Continue to monitor

The health care provider prescribes 10 units per liters of oxytocin via IV drip to augment a client's labor because she's experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin.

Contraction duration of 100 seconds.

A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contraction occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time.

Contractions decrease with walking.

The nurse is caring for a multiparous client who is 8 centimeters dilated 100% effaced and the fetal head is at 0 station. The clients is shivering and states extreme discomfort with the urge to bear down. which intervention should the nurse implement?

Encourage pushing with each contraction.

A 17 year old client gave birth 12 hours ago she states that she doesn't know how to care for her baby. To promote parent infant attachment behaviors which intervention should the nurse implement.

Encourage rooming in while in the hospital

A client with 26 weeks gestation was informed this morning that she has an elevated alpha fetal protein (AFP) level. After the health care provider leaves the room, the client asks what she should do next. What information should the nurse provide.

Explain that his sonogram should be scheduled for definitive results.

A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. which assessment warrants immediate intervention by the nurse.

Fetal Heart rate 60 beats per minute

The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of eight pounds 3629 grams at 36 weeks gestation. This amniocentesis is being performed to obtain which information

Fetal lung maturity.

On the first postpartum day the nurse examines the breast of a new mother. Which condition is the nurse most likely to find.

Filling and secreting colostrum.

A newborn assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?

Folic acid deficiency

A newborn assessment reveals spina bifida occulta. Which maternity factors should nurse identify as having the greatest impact on the development of this newborn complication.

Folic acid deficiency

A 3-hour old male infants hands and feet as cyanotic, and has an axillary temperature of 96.5 degrees Fahrenheit 35.8 degrees centigrade a respiratory rate of 40 breaths per minute and a heart rate of 165 beats per minute what nursing action should nurse implement

Gradually warm the infant under a radiant heat source.

client tells the nurse that she thinks she's pregnant. Which signs or symptoms provide the best indication that the client is pregnant.

Hegar's sign.

A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes the nurse observes several shallow small vesicles on her pubis labia and perineum. the nurse should recognize the clients is prohibiting symptoms of which condition?

Herpes Simplex Virus

The mother of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right she tells the nurse, "Now my daughter is not getting enough to eat" which response would be best for the nurse to make.

If your baby's urine is straw colored, she's getting enough milk.

At 12 hours after the birth of a healthy infant the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. which action should nurse take?

Inspect clients perineal and rectal areas

A new born nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a new born admission. What action should the nurse take to ensure adequate installation of the client.

Instill a thin ribbon into each lower conjunctival sac

A 16 year old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

Keep an airway at the bedside

If primigravida at 36 weeks gestation who is RH negative experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the health care provider?

Mild contractions every 10 minutes

The nurse is receiving report for a laboring client who arrived in the emergency center which ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client his admitted to the labor and delivery suite?

Monitor amniotic fluid for meconium.

Four client at full term present to the labor and delivery unit at the same time. which client should a nurse access first.

Multipara with contractions occurring every three minutes.

A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is priority nursing action for this client?

Observe for signs of uterine hemorrhage

A client who is 24 weeks gestation arrives to the clinic reporting swollen hands. On examination the nurse notes the clients as had a rapid weight gain over six weeks. which action should a nurse implements next?

Obtain the clients blood pressure.

A mother spontaneously delivers a newborn infant in the taxicab while on the way to the hospital the emergency room nurse reported the mother as active herpes (H5V III) lesions on the vulva. Which intervention should the nurse implement first when admitting the neonate to the nursery?

Place the newborn in the isolation area of the nursery.

A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse assessment reveals approximately 30ML of bright red vaginal bleeding. Fetal rate of 130 - 140 beats per minute, no contractions and no complaints of pain what is the most likely cause of these client's bleeding.

Placenta Previa

The nurse is preparing to administer phytonadione to a newborn. Which statement makes made by the parents indicates understanding why the nurse is administering this medication.

Prevent hemorrhagic disorders.

In The Ballard Gestational Age Assessment Tool, the nurse determines that a 15-month-old infant as a gestational age of 42 weeks. Based on this finding which intervention is most important for the nurse to implement.

Provide a capillary blood glucose

A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contraction 5 minutes apart while the client is in the bathroom changing into a hospital gown the nurse hears the noise of a baby what should the nurse take first?

Push the call light for help

A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7 pounds infant 4 hours ago by cesarean delivery. Which nursing problem has the highest priority?

Risk for injury related to uterine atony

A 38-week primigravida is admitted to labor and delivery after a non-reactive result on a non- stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin infusion. Which finding is most important for the nurse to report to the health care provider.

Spontaneous rupture of membranes.

Examination reveals that the laboring clients cervix is dilated to 2 centimeters, 70% effaced with the presenting part at -2 station the client tells the nurse I need my epidural now, this hurts, the nurses response to the client is based on which information.

The client will need to be catheterized before the epidural can be administered.

A pregnant client mentions in a history that she changes cats litter box daily. Which test should the nurse anticipate the health care provider to prescribe.

Torch screening

A client who delivered a healthy newborn an hour ago asked the nurse when can she go home. Which information is most important for the nurse to provide the client.

When there is no significant vaginal bleeding.