Maternity Hesi Questions
The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug?
Blood pressure 149/90.
The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this fiding?
Both the lower uterine segment and the fundus must be massaged.
A blind litter girld, 8 year sold was admitted to the hospital what can you do to make her comfortable
Bring familiarly toys from home, such as bear,doll.
Primipara patient. What is the pet to share time a, home that is not recommended?
CAT
A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse to review before reporting to the healthcare provider?
Calcium
A child who received multiple blood transfusions after correction of a congenital heart defects is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse before reporting to the healthcare provider? · CO combining power · Calcium · Sodium · Chloride
Calcium
A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time?
Contractions decrease with walking
The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.) A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. E. Has a disheveled appearance.
A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts.
One day after vaginal delivery of a full term baby, a postpartum client's white blood cell count is 15.000/mm. What action should the nurse take first? · Check the differential, since the WBC is normal for this client · Assess the client's temperature, pulse, and respirations q4h · Assess the client's perineal area for signs of a perineal hematoma · Notify the healthcare provider, since this finding is indicative of infection
Check the differential, since the WBC is normal for this client
One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?
Check the differential, since the WBC is normal for this client
Which toy is most appropriate for a 10-year-old child with acute rheumatic fever who is on strict bedrest?
Checkers
Diaper
Clean water
During a routine clinic visit, the nurse determines that a 5-year-old boy's blood pressure is 112/70. When calculating the child's blood pressure percentile, the nurse adjusts the calculation for age and height. What actions should the nurse implement next?
Compare the child's blood pressure with readings from previous visits
The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which answer should the nurse to provide?
" Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider"
The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and a 12-year-old sibling are the child bedside. Which instruction best supports this family?
" While waiting for the healthcare provider, only one visitor may stay with the child"
The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has triple compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?
"What food does your baby usually eat in a normal day?"
The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer?
0.3
A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer?
13
A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only)
75
A 7 year old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history which finding should the nurse expect to obtain? · High blood cholesterol level on routine screening · Increased thirst and urination · A recent strep throat infection · A recent DPT immunization
A recent strep throat infection
The nurse assessing a 9-year old boy who has been admitted to the hospital with possible acute postsreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? · Back pain for a few days · A history of hypertension · A sore throats last week · Diuresis during the nights
A sore throats last week
A two year old child with a heart failure(HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What action should the nurse implement? · Determine the pulse deficit · Administer the schedule dose · Calculate the safe dose range · Review the serum digoxin level
Administer the schedule dose
A child with leukemia is admitted for Chemotherapy and the nursing diagnosis " altered nutrion, less those body requirements related to anorexia, nausea and vomiting" is identified. Which intervention the nurse included in this child plan of care?
Allow the child to eat any food desired and tolerated.
A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide?
Apply hot packs just before each feeding
A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby lactch on
A new mother is having trouble breast feeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
Ask the mother to stop feeding, confront the infant, and then assist the mother to help the baby latch on.
A newborn yellow abdomen and chest
Assess bilirubin level
A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? · Turn the client to her left side · Contact the healthcare provider · Assess the fetal heart rate · Check the cervical dilation
Assess the fetal heart rate
A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? · Discuss the need for cortisol and aldosterone replacement therapy after discharge · Support the parents in their decision to assign sex of their child according to their preference · Offer information about ultrasonography and genotyping to determine sex assignment · Explain that corrective surgical procedures consistent with sex assignment can be delayed
Discuss the need for cortisol and aldosterone replacement therapy after discharge
A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform?
Babinski's reflex
The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. · Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 · Ampicillin 1 gram IV push q8h. · Betamethasone (Celestone) 12 mg deep IM · Butorphanol (Stadol) 1 mg IV push q2h PRN pain
Betamethasone (Celestone) 12 mg deep IM
The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome?
Betamethasone (Celestone) 12 mg deep IM
The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement?
Document the vital signs in the record
The nurse is providing preoperative teaching to a teenaged client with appendicitis information should the nurse include about postoperative activity?
Early ambulation after surgery will be encouraged to reduce complications and promote healing
At 6-weeks gestation, the rubella titer of 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
During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client.
Elevate the head with two pillows while sleeping
During a well-child visit for their child, one of the parent who has an autosomal dominant disorder tells the nurse, "We don't plan on having any more children, since the next child is likely to inherit this disorder". How should the nurse respond? · Explain that the risk of inhering the disorder decrease by 50% with each child the couple has · Acknowledge that the next that the next child will inherit the disorder since the first child did not · Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked · Confirm that there is a 50% chance of their future children inheriting the disorder
Confirm that there is a 50% chance of their future children inheriting the disorder
During a well-child visit for their child, one of the parents who has an autosomal dominant disorder tells the nurse, "We don't plan on having any more children, since the next child is likely to inherit this disorder." How should the nurse respond?
Confirm that there is a 50% chance of their future children inheriting the disorder
A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?
Contact the healthcare provider
A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? · Pain level · Blood pressure · Infusion site · Contraction pattern
Contraction Pattern
A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?
Contraction pattern
The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? · Respiratory rate of 22 breaths/min · A large amount of lochia rubra · Blood pressure 149/90 · Positive Homan's sign
Blood pressure 149/90
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
Propanol
Decrease headache
A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first?
Determine current cervical dilation
An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take?
Determine the infant's blood sugar level
To confirm RDS in a newborn
Diagphrama breathing
ADHD
Encourage the parents to help the baby with homework
The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? · Begin a training program lifting weights and running · Splint affected joints during activity · Exercise in a swimming pool · Perform passive range of motion exercises twice daily
Exercise in a swimming pool
The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
Exercise in a swimming pool.
A 4 month old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? · Bilateral bronchial breath sounds · Diaphragmatic respiration · A resting respiratory rate of 35 breathe per minute · Flaring of the nares
Flaring of the nares
A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2-station. What action should the nurse implement first? · Decrease the oxytocin infusion rate · Determine current cervical dilation · Request placement of the epidural · Give a bolus of intravenous fluids
Give a bolus of intravenous fluids
Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority?
Have a meconium aspirator available at delivery
A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? · Obtain a culture of any sputum or wound drainage · Initiate normal saline IV at 50 ml/hr · Administer a loading dose of penicillin IM · Administer the initial dose of folic acid PO
Initiate normal saline IV at 50 ml/hr
A 5-year-old child is admitted to the pediatric unit fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first?
Initiate normal saline IV at 50ml/hr
While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?
Inspect the posterior oropharynx
Palirizumab (synagis)
Is given to high risk baby
Watery vaginal white in the first trimester
Is normal
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? · Keep airway equipment at the bedside. · Allow liberal family visitation · Monitor blood pressure, pulse, and respirations q4h · Assess temperature q1h
Keep airway equipment at the bedside.
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what information is most important for the nurse to provide?
Maternal blood pressure
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the condition, what information is most important for the nurse to provide?
Maternal blood pressure
A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit?
Metabolic Alkalosis
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for wich acid base alteration?
Metabolic acidosis
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis af eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?
Monitor Blood pressure, pulse, and respirations q4h
Which instruction should the nurse include in the discharge teaching plan of a 7-year-old girl with a history of frequent urinary tract infections?
Monitor for changes in urinary odor.
The nurse is caring for a one-year-old child following surgical correction of hypospadias. The nursing action has the highest priority? · Monitor urinary output · Auscultate bowel sounds · Observe appearance of stool · Record percent of diet eaten
Monitor urinary output
The nurse is caring for a one-year-old child following surgical correction of hypospadias. What nursing action has the highest priority?
Monitor urinary output
A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? · Alert the neonatal team and prepare for neonatal resuscitation · Notify the healthcare provider from the client's bedside · Obtain written consent for an emergency cesarean section · Draw a blood sample for stat hemoglobin and hematocrit
Notify the healthcare provider from the client's bedside
A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?
Offer information about ultrasonography and genotyping to determine sex assignment
The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client's teaching plan?
Oral contraceptive use for at least one year.
The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, and notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to the body size. Which action is most important for the nurse to take next?
Palpate the anterior fontanel for tension and bulding
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea ( sudden aimless movements of the arms and legs). Which information should the nurse tell to the parents?
The chorea or movements are temporary and will eventually disappear
The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next? · Measure the infant's head to heel length · Observe the infant for sunset eyes · Palpate the anterior fontanel for tension and bulging · Plot the measurement on the infant's growth chart
Palpate the anterior fontanel for tension and bulging
The nurse has completed a teaching plan for the mother of a child who is taking digitalis and a diuretic for treatment of the heart failure. Choosing which lunch would indicate that the mother understands the best diet for her child?
Peanut butter and banana sandwich with orange juice
An infant with letralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? · Administer morphine sulphate · Start IV fluids · Place the infant in a knee-chest position · Provide 100% oxygen by face mask
Place the infant in a knee-chest position
A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first?
Place the infant on the abdomen to protect the sac
The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12 year old sibling at the child's bedside. Which instruction best supports family? · While waiting for the healthcare provider, only one visitor may stay with the child · All of you should leave while the healthcare provider sutures the child's forehead · It is best if the sibling goes to the waiting room until the suturing is completed · Please decide who will stay when the healthcare provider begins suturing
Please decide who will stay when the healthcare provider begins suturing
Cryptorchidism
Put baby in a room and calm the baby
The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child?
Reduce cerebral edema and lower intracranial pressure
The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child? · Reduce cerebral edema and lower intracranial pressure · Avert hypotension and septic shock · Prevent cardiac arrhythmias and heart failure · Promote kidney perfusion and normal blood pressure.
Reduce cerebral edema and lower intracranial pressure
Child HIV
Respiratory system
What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes?
Restrict carbohydrate intake
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chronic (sudden aimless movements of the arms and legs). Which information should the nurse to the parents? · Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged · The chorea or movements are temporary and will eventually disappear · Permanent life-style changes need to be made to promote safety in the home · Consistent discipline is needed to help the child control the movements
The chorea or movements are temporary and will eventually disappear
A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?
Stimulate the infant to cry
Glomerunephritis
Strawberry
A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant's skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)?
Sweat-chloride test
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding?
The TSH is high because of the low production of T4 by the thyroid.
Patient with Duchenne Disease. The nurse has to explain to the mother that:
This condition is inherited in an X-linked recessive chromosome pattern
The parents of a 3 year-old boy who has Duchenne muscular dystrophy (DMD) ask "how can our son have this disease? We are wondering if we should have any more children" What information should the nurse provide these parents? · This is an inherited X-linked recessive disorder, which primarly affects male children in the family · The male infant had a viral infection that went unnoticed and iuntreated, so muscle damage was incurred · The XXXX muscle groups of males can be impacted by a lack of the protein dystrophyn in the mother · Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles
This is an inherited X-linked recessive disorder, which primarly affects male children in the family
A client with gestational diabetes is undergoing a non-stress test (NST) at 34-weeks gestation. The baseline fetal heart rate (FHR) is 144 beats/minute. The client is instructed to mark the fetal monitor paper by pressing a button attached to the fetal monitor each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. Which outcome indicates a reactive NST?
Two FHR accelerations of 15 beats/minute x 15 seconds are recorded
A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin (Nix) shampoo and calls his parents. What instruction should the nurse provide to the parents about treatment for head lice?
Wash the child's bed linens and clothing in hot soapy water.
Which nursing intervention is most important to include in the plan of care for for a child with acute glomerulonephritis? · Encourage fluid intake · Promote complete bed rest · Weight the child daily · Administer vitamin supplements
Weight the child daily
A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? · Carrots · Chicken · Yogurt · Cheese
chicken
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? · Respiratory alkalosis · Respiratory acidosis · Metabolic acidosis · Metabolic alkalosis
metabolic acidosis
A child has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? · Respiratory alkalosis · Respiratory acidosis · Metabolic alkalosis · Metabolic acidosis
metabolic alkalosis
A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?
obtain written consent for an emergency cesarean section
The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute poststreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant?
sore throat last week