Karen HESI Exam Version 2

The nurse is reviewing a woman's health care records during her first prenatal visit. The client has a history of chickenpox as a child and syphilis as a teenager. Which action is most important for the nurse to take?

Explain common complications of pregnan

The mother of a breastfeeding 24 hr 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, "I just know my daughter is not getting enough to eat." What response would be best for the nurse to make?

"if your baby's urine is straw-colored, she is getting enough milk"

When assessing a pregnant woman at 39 weeks gestation who is admitted to labor and delivery, which finding is most important to report to the HCP?

101.2 F oral temp

A postpartum client who is giving her new baby formula feedings asks the nurse when she should expect to start menstruating again. What information should the nurse tell the client ?

6 to 8 weeks after birth

The charge nurse working on a postpartum unit is making assignments for a staff consisting of a nurse, practical nurse and 2 unlicensed assistive personnel. Which client should the charge nurse assign to the practical nurse?

A multigravida who delivered during c section 20 min ago and needs her vital signs taken.

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

Absence of patellar reflex (magnesium Sulfate toxicity)

Vaginal examinations reveal that a laboring client cervix is dilated 2cm, 70% effaced, with presenting part at -2 station. The client tells the nurse " I need my epidural now! This hurts!" The nurse response to the client should be based on which information?

Administering an epidural at this point would slow the labor process

A new mother calls the nurse stating that she wants to start feeding her 6 month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?

Advise the mother to wait at least another month before starting any solid foods

When planning care for a laboring client, the nurse identifies the need to withhold solid foods while the client is in labor. What is the most important reason for this nursing intervention?

An increased risk for aspiration can occur if general analgesic is needed.

A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?

Apply suprapubic pressure

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

Ascertain the frequency of headaches

A woman who delivered a 9 pound baby boy by cesarean section under spinal anesthesia is recovering in the postanesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous trickle of bright red blood with no clots from the vagina is observed by the nurse. Which action should the nurse implement?

Assess her blood pressure

A woman at 36-weeks' gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramp. She is placed on a strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?

Assess the fetal heart rate & client's contraction pattern

The nurse notes that a newborn at 24hrs of age has a large cephalhematoma. Which intervention has the highest priority?

Assess the infant for jaundice every 8 hours

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

Change position to left lateral

An oxytocin induction was started for a gravid client 6 hours ago. When assessing the FHR on the electronic fetal monitor, the nurse notes a "U-shaped" pattern.. Which intervention should the nurse implement first?

Change the position of the client

A pregnant woman in the first trimester of pregnancy has a Hb 8.6 mg/dL and HCT 25.1%. What food should the nurse encourage this client to include in her diet?

Chicken

A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of which condition?

Chorioamnionitis

A client at 10- weeks gestation calls the clinic reporting a low-grade fever with moderate cramping and heavy bright -red bleeding. Which instruction should the nurse provide the client?

Come in for immediate evaluation

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Cries vigorously when stimulated

The home health nurse visits a client who delivered a full term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curd-like patches on the newborn's oral mucous membranes. What action should the nurse implement?

Discuss the need for medication to treat curd-like oral patches

A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?

Disseminated intravascular coagulation (DIC)

At 6-weeks gestation, the rubella titer for a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?

Early postpartum, within 72 hours of delivery.

An ambulatory client at 39-weeks gestation presents to the emergency center with an obvious injury to her arm that occured as the result of a fall. Which concurrent symptom is a priority for the nurse to address further?

Ecchymotic knees

The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. Which action is most important for the nurse to take?

Encourage the mother to hold and spend time with her baby.

The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

Encourage voiding

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?

Evaluate infant feeding techniques prior to discharge

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Explain that a sonogram should be scheduled for definitive results.

A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

Fetal growth and gestational age.

While assessing a 40-week gestation primigravida in active labor, the client's membranes rupture spontaneously and the nurse notes that the amniotic fluid is meconium stained. Which additional finding is most important for the nurse to report to the healthcare provider?

Fetal heart rate of 100 to 110 beats/minute

When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum and abdomen. Which action should the nurse take?

Measure bilirubin levels using transcutaneous bilirubinometry

The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

Heart rate & blood pressure

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

Hypoglycemia

Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs. (3, 402 grams), weighs 7 lbs (3,175 grams) today?

Inform and assure the mother that this is a normal weight loss

Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs?

Inform and assure the mother that this is normal weight loss.

During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement ?

Inform her that this is a normal physiological change

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Inform the anesthesia care provider

A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor?

Intensity, interval, and length of contractions

The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, Facial and hand sweating, complaints of blurry vision, and a severe frontal headache. Which medication should the nurse anticipate for this client?

Magnesium sulfate

The nurse performs a routine assessment on a 12-hour-old infant. Which finding requires intervention?

No voiding or stooling since birth

33. An unlicensed assistive personnel (UP) reports to the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6°F (37° C). The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?

Notify the healthcare provider of the assessment findings

The nurse is caring for a client who is 10-weeks' gestation and palpates the funds at 2 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Obtain HCG levels

The nurse is assessing a newborn who was precipitously delivered at 38- weeks gestation. The newborn is tremulous, tachycardia, and hypertensive. Which assessment action is most important for the nurse to implement ?

Obtain a drug screen for cocaine

The nurse is providing anticipatory guidance for an African-American client who is at 24-weeks gestation. Which prenatal lab assessment, prescribed at 28-weeks, should the nurse include?

One-hour glucose screen

The nurse is caring for a client who is 24-weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

Oral glucose challenge test

Following the vaginal delivery of a 10-pound (4536 gram) infant, the nurse assesses a new mother's vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. Which action should the nurse implement first?

Perform fundal massage until firm.

The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit. Which action should the nurse perform?

Place procedure equipment at bedside

Upon admission to the nursery, the nurse places a newborn supine under a radiant warmer, an external heat source. What intervention should the nurse implement first to ensure safe thermoregulation ?

Place temperature probe on the abdomen in the line with the radiant heat source

A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse's assessment reveals approximately 30 ml of bright red vaginal bleeding, FHR of 130 to 140 beats/min, no contraction, and no complaints of pain. What is the most likely case of this client's bleeding?

Placenta previa

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eye. He asks the nurse what the purpose of the ointment is. The nurse would be correct in stating that the purpose for using the ointment is to ?

Prevent eye infection

Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum?

Pudendal block

Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Pulse rate of 56 bpm

A primipara client at 42-weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated; contractions are occurring every 1 minute with a 75 second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20 second duration. Which intervention should the nurse implement?

Restart oxytocin infusion rate per protocol

At a prenatal visit, a primigravida client confides to the nurse that her partner is abusive. Which information should the nurse provide?

Safety plan to keep in a purse at all times

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, *I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?" Which information should the nurse provide?

Start a prenatal care plan as soon as possible

After two miscarriages, a client is Instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid

Strawberries

Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

Swaddle the infant in a warm blanket

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

Test the fluid with a nitrazine strip

A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond?

That is called caput succedaneum. It will absorb and cause no problems.

The nurse is caring for a 2-day-old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate x-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?

The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis

A client in preterm labor has had an infusion of magnesium sulfate running 8 hrs. Current assessment finding are: RR 14 bpm, UOP 24

The finding indicate potential toxicity to magnesium sulfate and close follow up is indicated.

A gravida 3 para 3 who is Rh-negative delivers a full-term infant at home with the assistance of a nurse midwife. Two days later, the client calls the clinic to ask if it is necessary to see the healthcare provider since the infant is healthy, and she is not having any complications. The woman's history indicates that both previously born infants were Rh-negative. Which response should the nurse provide?

The newborn's blood type should be tested to determine the need for RhoGAM

A is necessary to see the healthcare provider since the infant is healthy, and she is not having any complications. The woman's history indicates that both previously born infants were Rh-negative. Which response should the nurse provide?

The newborn's blood type should be tested to determine the need for RhoGAM

A client who is receiving oxytocin to augment early labor begins to experience tachy systolic or tetanic contractions with variable fetal heart deceleration. Which action should the nurse implement?

Turn off the oxytocin infusion

A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?

Using alternative form of birth control until new diaphragm can be obtained

A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?

Visualization of implantation by vaginal ultrasound

At 34 weeks gestation, a primigravida is assessing at her bimonthly clinic visit. Which assessment finding is important for the nurse to report to the HCP.

Weight gain of 7 lbs

A new mother asks the nurse why her infant son has a needle mark on his leg. Which response is best for the nurse to provide the mother?

Your baby was given an injection of vitamin K to prevent bleeding

A primiparous client delivered via cesarean section 24 hours ago. Which behavior should the nurse expect the client to exhibit?

ccepts the birth was not as expected.

The client will need to be catheterized before the epidural can be administered. A client who is HIV+ is receiving zidovudine during labor. Which information should the nurse provide to the client?

his treatment helps prevent transmission of the virus to the fetus.