Maternity HESI questions

The nurse is instructing then client to cough and deep breath after an emergency c-section under general anesthesia. The client says, "get out of here. Can't you see that I'm in pain?" Which response will be the most effective at this time? A. "I'm sure you're in pain. I'll come back later" B. "If you can't cough, try taking very deep breaths" C. "Your pain is to be expected, but you must exercise your lungs" D. "I'll give you something for your pain. We can start the coughing tomorrow"

B - -prevents stasis of pulmonary secretions

A client with preeclampsia has delivered and is receiving magnesium sulfate postpartum. Which nursing action is the priority during the immediate 4 hours after delivery? A. monitoring blood pressure B. monitoring urinary output C. observing amount of lochia D. assessing breast feeding technique

C - -increased risk of hemorrhage d/t both preeclampsia and use of magnesium sulfate

A client is receiving magnesium sulfate therapy for severe preeclampsia. Which initial sign of toxicity would prompt the nurse to intervene? A. hyperactive sensorium B. increase in respiratory rate C. lack of the knee-jerk reflex D. development of a cardiac dysrhythmia

C - -magnesium sulfate has a depressant effect on the CNS

Which statements regarding the involution process are correct? A. involution begins immediately after expulsion of the placenta B. involution is the self-destruction of excess hypertrophied tissue C. involution progresses rapidly during the next few days after birth D. involution is the return of the uterus to a non pregnant state after birth E. involution may be caused by retained placental fragments and infections

A, C, D

A client at 36 hours postpartum is being treated with subcutaneous enoxaparin for DVT of the left calf. Which client adaptation is of most concern to the nurse? A. Dyspnea B. Pulse rate of 62 C. BP of 136/88 mm Hg D. positive Homan sign in the left leg

A - -significant sign of pulmonary embolism

The nurse is caring for a postpartum client with preeclampsia being managed with a magnesium sulfate infusion. Which is the priority nursing assessment? A. counting respiratory rate B. obtaining blood pressure C. eliciting deep tendon reflexes D. monitoring urine output

A - -these are all appropriate assessments but one is priority

Which postpartum client would the nurse assess first? A. Client who vaginally delivered a 7-lb (3175g) baby 1 hour ago B. Client who vaginally delivered a 9-lb (4082g) baby 1 hour ago C. Client who vaginally delivered a preterm baby 4 hours ago D. Client who had a planned c-section of an 8-lb (3629g) baby 2 hours ago

B - -this patient is at risk for postpartum hemorrhage; the uterus may have been overly-distended from the large fetus causing uterine atony (the main cause of PP hemorrhage)

The nurse is caring for 4 postpartum patients, each with a different medical condition. Which condition will result in the PHCP advising the new mother not breastfeed? A. Mastitis B. Inverted nipples C. Herpes genitalia D. Human immunodeficiency virus (HIV) infection

D

Which factor explains why a breastfeeding mother who is 3 days postpartum complains that her breasts are tight and swollen? A. There is an overabundance of milk B. Breast-feeding is probably ineffective C. The breasts have been inadequately supported D. The lymphatic system in the breasts is congested

D

Which is the expected location of the uterine fundus immediately after a vaginal birth and expulsion of the placenta? A. In the pelvic cavity B. Just below the diploid process C. In the right quadrant at the umbilicus D. Halfway between the symphysis pubis and the umbilicus

D

Which meaning would the nurse assign to the observation that a client is voiding frequently in small amounts 8 hours after giving birth? A. it may indicate retention of urine with overflow B. it may be indicative of beginning pyelonephritis C. this is common because less fluid is excreted after birth D. this is common because fluid intake diminishes after birth

A

Which precaution would the nurse institute for a client with a diagnosis of severe preeclampsia? A. padding the side rails on the bed B. placing the call button next to the client C. having oxygen and a face mask available D. assigning a nursing assistant to stay with the client

A

Which finding does the nurse expect when checking the vitals of a client in the early postpartum period? A. Bradycardia with no change in respiration B. Tachycardia with a decrease in respirations C. Increased basal temperature with a decrease in respirations D. Decreased basal temperature with an increase in respirations

A - -A slow pulse rate may result from decreased cardiovascular workload, emotional relief and satisfaction, and rest after labor and birth

By which mechanism do sitz bath aid in healing of an episiotomy? A. promoting vasodilation B. cleansing perineal tissue C. softening the incision site D. tightening the rectal sphincter

A - -Heat causes vasodilation and increased blood supply to the area

How would the nurse respond to a client who after birth says, "I'm so cold and I can't stop shaking"? A. "I'm going to take your temperature right now" B. "Let me check your uterus to see whether its firm" C. "Turn on your side so I can check the amount of lochia" D. "I'll get you some warm blankets to make the chill go away"

D - -A postpartum chill is an expected vasomotor reaction

Which additional nurse care is needed for the postpartum client after a C-section due to her post surgical status? A. encouraging early ambulation B. assessing the fundus gently but firmly C. checking vital signs for evidence of shock D. Administering the prescribed pain medication

D - -Because of increased pain & flatus, clients who have had a cesarean birth retire more pain medication than women who have vaginal births

Which information in a postpartum client's health history would alert the nurse to monitor the client for signs of infection? A. three spontaneous abortions B. B-negative maternal blood type C. blood loss of 850 mL after a vaginal birth D. temperature of 99.9 F during the first postpartum day

C - -excessive blood loss predisposes the client to infection because of decreased maternal resistance

12 hours after a spontaneous birth a client's temperature is 100.4 F (38 C). Which condition would the nurse suspect as the cause of the increased temperature? A. mastitis B. dehydration C. puerperal infection D. urinary tract infection

B

Late fetal heart rate decelerations begin to appear when a clients cervix is dilated 6 cm and her contractions are occurring every 4 min and lasting 45 sec. Which is the likely cause of these late decels? A. imminent vaginal birth B. uteroplacental insufficiency C. pattern of nonprogressive labor D. normal pressure on the presenting part during contractions

B

Which intervention would the nurse recommend for post-cesarean gas pain? A. Lying on the right side B. Walking around the room C. Using a straw when drinking water D. Supporting the incision when moving

B

Which behavior would the infant exhibit if an adequate amount of breast milk is being ingested? A. Has several firm stools daily B. Voids 6 or more times a day C. Spits out a pacifier when offered D. Awakens to feed about every 4 hours

B

Which combination of maternal and infant blood type would be an indication for Rho (D) immune globulin (RhoGAM) to the postpartum client? A. mother A pos and infant O pos B. mother O neg and infant O pos C. mother AB neg and infant B neg D. mother B pos and infant B neg

B

The nurse is teaching breast feeding to a newly delivered client. Which statement by the client indicates the need for further instruction? A. "I'll try to empty my breasts at each feeding" B. "I'll alternate between breasts to start feedings" C. "I need to wash my breasts with soapy water before I breast feed" D. "I need to stroke my baby's cheek gently when I'm ready to breast feed"

C

When would the risk of another seizure in a pt with eclampsia decrease? A. after birth occurs B. after labor begins C. 48 hours postpartum D. 24 hours postpartum

C

The day after a client has a cesarean birth, the indwelling catheter is removed. The nurse concludes that urinary function has returned when the: A. client has 90 mL of residual urine after voiding B. client's daily urinary output is at least 1500 mL C. client's urinalysis indicates that no bacteria are present D. client voids 300 mL of urine within 4 hours of catheter removal

D

1 hour after birth the nurse palpate a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and 2 finger breadths below the umbilicus. Which would the nurse do next? A. Encourage the client to void B. Notify the HCP immediately C. Massage the uterus and attempt express clots D. Continue periodic assessments and record the findings

D - -Immediately after birth the uterus is 2 cm below the umbilicus. During the first several hours postpartum, the uterus will rise slowly to just above the umbilicus

What is the priority finding in the care of a newborn receiving phototherapy for high bilirubin? A. sunken fontanels B. maculopapular skin rash C. conjunctivitis D. bronze skin discoloration

A - -indication of dehydration

Between which weeks of gestation would a client with type 1 diabetes expect to increase her insulin dosage? A. 10th and 12th weeks of gestation B. 18th and 22nd weeks of gestation C. 24th and 28th weeks of gestation D. 36th and 40th weeks of gestation

C - -Increase insulin because an increase in maternal resistance to insulin occurs. During the last few weeks, maternal resistance to insulin decreases

Within minutes of giving birth to a healthy infant, a client displays symptoms of respiratory distress and an amniotic fluid embolism is suspected. For which other complication would the nurse assess this client? A. Hypertension B. Uterine atony C. Thrombophlebitis D. Uncontrolled bleeding

D - -disseminated intravascular coagulation is associated with amniotic fluid embolism; both problems may occur after premature separation of the placenta

Why is a multiple-gestation pregnancy considered a high risk? A. postpartum hemorrhage is an expected complication B. perinatal mortality is 2-3 times more likely in multiple than in single births C. optimal psychological adjustment after a multiple births requires 6 months to a year D. maternal mortality is higher during the prenatal period in the setting of multiple gestation

B - -greater metabolic demands & the malpositioning of one or more fetuses

The nurse suspects a thrombus after assessing a client who has pain in her right calf 2 days after a c-section. What is the nurse's immediate action? A. Confine client to bed B. Apply warm socks C. Perform leg exercises D. Massage the affected area

A

Which postpartum client is at the highest risk for disseminated intravascular coagulation (DIC)? A. Gravida III with twins B. Gravida V with endometriosis C. Gravida II who had a 9-lb baby D. Gravida I who has had an intrauterine fetal death

D

When assessing frequency of contractions, the time is measured between which two events? A. the beginning of a contraction to the end of the contraction B. the end of one contraction to the start of the next contraction C. the beginning of one contraction to the beginning of the next contraction D. the complete relaxation of the uterus at the end of a contraction to the start of the next contraction

C

Which common indication for a cesarean birth would the nurse discuss for expectant parents? A. placenta previa B. cervical insufficiency C. cephalopelvic disproportion D. primary uterine inertia

C

An 18 y.o. primigravida at 36 weeks' gestation is admitted with a diagnosis of mild preeclampsia. Which is the nurse's most important goal for the client at this time? A. easing her anxiety B. limiting the bleeding C. reducing her blood pressure D. decreasing the circulating blood volume

C

Which microorganism causes maternal mastitis? A. Escherichia coli B. Group B streptococcus C. Staphylococcus aureus D. Chlamydia trachomatis

C

Which assessment would the nurse include in the plan of c are for a postpartum client with large, painful varicose veins? A. Monitoring daily clotting times B. Assessing for peripheral pulses C. Monitoring daily hemoglobin levels D. Assessing for signs of thrombophlebitis

D

A client at 6 weeks postpartum confides that she is experiencing exhaustion that is not relieved by sleep and feelings of failure as a mother because the infant cries all the time. When asked whether she has a support system, she says she lives alone. Which action would the nurse perform next? A. provide information about a local support group B. explain that it can be normal to feel emotional changes, doubt, and fatigue after childbirth C. ask the client questions using a postpartum depression scale D. suggest the client find someone who can take care of the baby for 24 hours

C

Which nursing intervention is the priority during the first 2 hours after cesarean birth? A. evaluating fluid needs to maintain optimum hydration B. monitoring the incision to help prevent the onset of infection C. encouraging bonding to promote mother-infant interaction D. assessing the lochia to identify the complication

D

During the second postpartum hour a client who has heavy vaginal bleeding that does not diminish after fundal massage says, "I'm so thirsty. May I have some ginger ale?" Which is an appropriate reply by the nurse? A. "It's good to replenish your fluids. I'll bring you some ginger ale right away" B. "You want to drink to balance out the blood loss, but carbonated fluids are not a good choice" C. "I can imagine how thirsty you are, but I have to get clearance from the PHCP before I can give you anything to drink" D. "I know this is difficult, however it's best for you to wait until the bleeding has subsided. I can give you a moisturizer for your lips to relieve the dryness"

D - -the client should have nothing NPO while heavy bleeding continues because surgical intervention may become necessary and there is risk of aspiration

Which action would the nurse plan to take with a postpartum client with a negative rubella titer? A. Checking for allergies to penicillin B. Alerting the pediatrician C. Assuring the client that she has active immunity D. Obtaining a prescription for immunization at discharge

D - -Immunizations can be given safely during the immediate postpartum period but are teratogenic when given during pregnancy

Which complication is a pt with gestational hypertension at risk for? A. placenta previa B. polyhydramnios C. isoimmunization D. abruptio placentae

D - -vasospasms of placental vessels occur because of increased BP & as a result the placenta may separate prematurely

During the 1st hour after a c-section the nurse notes the client's lochia has saturated one perineal pad. Which clinical judgement would the nurse make based on this finding? A. scant lochial flow B. postpartum hemorrhage C. retained placental fragments D. Lochial flow within expected limits

D - -It is expected that as many as two pads will be saturated in the first hour

For which complication would the nurse closely monitor a client with a diagnosis of abruptio placentae? A. cerebral hemorrhage B. pulmonary edema C. impending seizures D. hypovolemic shock

D - -uterine bleeding can result in a massive internal hemorrhage

Which action would be the highest priority for the nurse to initiate for a client in eclampsia? A. prevent injury B. assess fetal heart tones C. maintain an open airway D increase the infusion rate

A

Which client behavior indicates to the nurse that further teaching regarding breast feeding is needed? A. If she leans forward to place her breast in the baby's mouth B. If she hold the infant level with her breast while in a side-lying position C. If she touches her nipple to the infant's cheek at the beginning of the feeding D. If she puts her finger in the infants mouth to break the suction after the feeding

A

A client's membranes ruptured 20 hours before admission. She gave birth 18 hours after admission. For which postpartum complication is the client at risk for? A. infection B. hemorrhage C. uterine atony D. amniotic fluid embolism

A - -The longer the time between the rupture of membranes and the birth, the greater the risk because microorganisms from the vagina may travel up to the embryonic sac

Which is the nurses most critical assessment for a client with preeclampsia during the immediate postpartum period? A. vital signs B. emotional status C. signs of hemorrhage D. signs of hypovolemic shock

A - -preeclamptic pts are at risk for compromised cardiovascular & renal function and seizure risk. Vitals need to be frequently assessed during the first 48 hours postpartum

Which finding, other than increased BP, may indicate preeclampsia? A. positive non stress test B. negative contraction stress test C. weight gain of 6-lbs in 1 month D. fetal heart rate below 120 beats/min

C

Which component of postpartum care is most important for the nurse to provide when helping a new mother develop her role as a parent? A. teaching her how to care for the baby B. providing time for her and the baby to be together C. responding to any questions she has about her baby's behavior D. demonstrating baby care and evaluating her return demonstration

B

Which impending problem would the nurse suspect when caring for a client with bloody urine in the indwelling catheter collection bag after an emergency c-section? A. Urinary infection from the catheter B. Incisional nick in the bladder C. Uterine relaxation with increased lochia D. Disseminated intravascular coagulopathy

B

Which intervention would the nurse plan for the breast feeding pt with a diagnosis of mastitis? A. Help her wean the infant gradually B. Teach her to empty her breasts frequently C. Review nutritional benefits of breast feeding D. Send a sample of her milk to the lab for testing

B - -emptying the breasts frequently prevents stasis of the milk and is part of the treatment for mastitis

24 hours after an uncomplicated labor and birth a client's complete blood count reveals a WBC count of 17,000. Which interpretation would the nurse assign to this finding? A. A normal, stress-related decrease in WBC's B. A sign of acute sexually transmitted viral infection C. An expected response to the process of labor and birth D. A manifestation of a bacterial infection of the reproductive system

C - -Usual postpartum WBC count is 15,00-20,00

Which instruction would the nurse provide to the breast feeding client with discomfort due to cracked nipples? A. stop nursing for a few days and allow the nipple to heal B. manually express milk and feed it to the baby in a bottle C. start feedings on the unaffected breast until the affected breast heals D. use a nipple shield to keep the baby from making direct contact with the nipple

C - -the most vigorous sucking occurs during the first few minutes of nursing so if the infant suckles on the unaffected breast, suckling on the affected breast later is less traumatic

The PHCP plans to perform a vaginal exam of a pt with a partial placenta previa. Which would the nurse have available when this exam is performed? A. one unit of freeze-dried plasma B. vitamin K and a syringe for injection C. heparin sodium for intravenous infusion D. two units of typed and cross-matched blood

D - -vaginal exam in a client w/ placenta previa may result in a sudden, severe hemorrhage because of the location of the placenta near the cervical os