maternity review hesi 1

A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding?

3.5 ounces.

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide?

A large body surface area favors heat loss to the environment.

The nurse on the postpartum unit receives report for 4 clients during change of shift. Which client should the nurse assess for risk of postpartum hemorrhage (PPH)?

A multiparous client receiving magnesium sulfate during induction for severe preeclampsia.

Which nursing intervention is the priority during the fourth stage of labor?

Assess for hemorrhage.

A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first?

Assess the fetal heart rate and pattern.

A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide?

The pregnancy should progress normally and be considered low risk.

An infant in respiratory distress is placed on pulse oximetry. The oxygen saturation indicates 85%. What is the priority nursing intervention?

Begin humidified oxygen via hood.

A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which food should the nurse recommend to increase the client's calcium intake?

Canned sardines.

While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding?

Caput succedaneum.

The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide?

Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy.

When assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next?

Document the finding as erythema toxicum.

A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to baseline before each contraction ends. What action should the nurse implement?

Document the finding in the client record.

A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this information, what action should the nurse implement?

Document the findings in the client record.

The nurse tells a client in her first trimester that she should increase her daily intake of calcium to 1,200 mg during pregnancy. The client responds, "I don't like milk." What dietary adjustments should the nurse recommend?

Eat more green, leafy vegetables.

Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor?

Encourage early initiation of breast or formula feeding.

While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change?

Fetal well being with labor progression.

The nurse is assessing a 12-hour-old infant with a maternal history of frequent alcohol consumption during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol syndrome (FAS)?

Flat nasal bridge.

The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the Dinamap display. What action should the nurse implement?

Give the infant medication for pain.

What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta?

Hard, board-like abdomen.

A client in the first stage of active labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light-headed, dizzy, and states that her fingers are tingling. What action should the nurse implement?

Help her breathe into a paper bag.

Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate?

Oral sucrose and nonnutritive sucking.

A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding should require the nurse to implement further action?

Intensity of contractions is 130 mm Hg.

Which action should the nurse implement when caring for a newborn immediately after birth?

Keep the newborn's airway clear.

The nurse administers meperidine (Demerol) 25 mg IV push to a laboring client, who delivers the infant 90 minutes later. What medication should the nurse anticipate administering to the infant?

Naloxone (Narcan).

Which procedure evaluates the effect of fetal movement on fetal heart activity?

Non-stress test (NST).

A client who is at 24-weeks gestation presents to the emergency department holding her arm and complaining of pain. The client reports she fell down the stairs. Which observation should alert the nurse to a possible battering situation?

Other parts of her body have injuries that are in different stages of healing.

Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)?

Pregnancy induced hypertension.

What action should the nurse implement to prevent conductive heat loss in a newborn?

Put a blanket on the scale when weighing the infant.

A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider?

Respiratory rate of 11 breaths/minute.

A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide?

Secretes both estrogen and progesterone.

A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide?

The fetus can respond to sound by 24-weeks gestation.

A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide?

The fetus in utero is capable of hearing and does respond to the mother's voice.

A client at 8-weeks gestation ask the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur?

The heart develops in the third to fifth weeks after conception.

A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client?

Ultrasonography.

At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention?

Uterine cramping.

A multiparous client is bearing down with contractions and crying out, "The baby is coming!" Which immediate action should the nurse implement?

Visualize the perineum for bulging.