Fortis-PN-Maternity Hesi Practice Exam

A primigravida client asks the practical nurse (PN), "How will I know that I will be going into labor soon?" Which sign should the PN provide that is a common sign? 1. Burst of energy. 2. Urinary retention. 3. Increase in fundal height. 4. Weight gain of 1.5 to 2 kg.

1. Burst of energy. Common information that woman often experience with impending labor is a burst of energy (A). Urinary frequency, not (B), and a decrease in fundal height, not (C), occur as the fetus drops into the pelvis with the onset of labor. (D) is not a sign of impending labor.

A father expresses concern that his 3-day-old infant looks "yellow." Which information should the practical nurse (PN) provide? 1. This yellow skin condition is the result of hepatic insufficiency. 2. Normal signs of jaundice occur during the first 24 hours of life. 3. Blood incompatibilities between mother and infant blood are common. 4. Physiologic jaundice occurs from a normal reduction in red blood cells.

4. Physiologic jaundice occurs from a normal reduction in red blood cells. Physiologic jaundice in the newborn is observed when an increase in indirect bilirubin levels peak (maximum serum levels of 5 to 6 mg/dl) between 2 to 4 days of age due to an immature newborn liver. Physiologic jaundice results in newborns due to the rapid lysis of red blood cells (RBCs) after birth (D). (A, B, and C) are inaccurate.

Which information should the practical nurse (PN) provide the parents about the purpose of instilling erythromycin (Ilotycin) ophthalmic ointment into the newborn's eyes? 1. Prevents the infant's eyelids from sticking together. 2. Destroys Staphylococcus overgrowth in eye exudate after birth. 3. Prevents obstruction of the infant's tear ducts. 4. Prophylactic treatment for gonorrheal and chlamydia infection.

4. Prophylactic treatment for gonorrheal and chlamydia infection. Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydia infection (D). The explanation should be based on state mandates for prophylactic ophthalmic ointment immediately after birth, not (A, B, and C), which are inaccurate.

Which client is a candidate for the administration of human immune globulin (RhoGam) after delivery? 1. The Rh-positive mother who delivers a Rh-positive baby. 2. The Rh-negative mother who delivers a Rh-negative baby. 3. The Rh-positive mother who delivers a Rh-negative baby. 4. The Rh-negative mother who delivers a Rh-positive baby.

4. The Rh-negative mother who delivers a Rh-positive baby. RhoGam is a human immune globulin that prevents the formation of anti-Rh antibodies in an Rh-negative mother who has given birth to an Rh-positive infant (D). (A, B, or C) are not candidates for RhoGam.

Which physiological cause(s) for constipation during pregnancy should the practical nurse (PN) explain to a client in the first trimester? (Select all that apply.) 1. Displacement of the colon. 2. Tightening of the anal sphincter. 3. Change in nutrient absorption. 4. Shifting of liver placement. 5. Decrease in peristalsis. 6. Increase bile production.

1. Displacement of the colon. 5. Decrease in peristalsis. During pregnancy, the enlarging uterus compresses and displaces the colon (A), which leads to a decrease in peristalsis (E), which contribute to constipation during pregnancy. (B, C, D, and F) do not cause constipation in pregnancy.

A 14-week gestational client, who weighed 125 pounds before pregnancy, comes into the health clinic for a prenatal appointment. The client's weight today is 129 pounds. What action should the practical nurse (PN) implement? 1. Document the finding in the medical record. 2. Retake the weight after calibrating the scale. 3. Notify the healthcare provider. 4. Obtain a 24-hour dietary recall.

1. Document the finding in the medical record. During pregnancy a client should gain between 25 to 35 pounds. The recommended weight gain during the first trimester is 3 pounds and approximately 1 pound/week for the remainder of the pregnancy. This finding is within the recommended weight gain and should be recorded in the client's medical record (A). (B, C, and D) are not indicated.

The practical nurse (PN) quickly moves the crib of a male newborn and notices that his legs flex, arms fan out, and then return toward his midline. What action should the PN implement? 1. Document the newborn demonstrates a Moro reflex. 2. Report the abnormal finding to the charge nurse. 3. Perform a hearing test for the newborn. 4. Observe for other abnormalities in the musculoskeletal system.

1. Document the newborn demonstrates a Moro reflex. The Moro reflex is a normal neonatal reflex that can be elicited when the infant's crib is jarred or a loud noise is made. (B and D) are not indicated. The presence of a Moro is not an indication to evaluate a newborn's hearing (C).

What is the most important action by the practical nurse (PN) in preventing neonatal infection? 1. Hand washing. 2. Isolating infected infants. 3. Adequate spacing of bassinets. 4. Practicing Standard Precautions.

1. Hand washing Almost all controlled clinical trials have demonstrated that effective hand washing (A) is the most responsible and the most important action for the prevention of nosocomial infection in nursery units. Other measures include implementing isolation policies for infants with potentially infectious conditions (B) and standard precautions (D). Other standards and policies in nurseries define procedures for careful and thorough cleaning, frequent replacement of used equipment, proper disposal of excrement and linens, and criteria to prevent overcrowding, such as the distance or spacing of bassinets (C) placed in a common area in the nursery.

The practical nurse (PN) is reviewing the informational packets with a client who is at risk for preeclampsia. Which information is most important for the PN reinforce with the client? 1. Notify the clinic if any vision changes are experienced. 2. Rest frequently with both feet elevated after long periods of standing. 3. Pack personal belongings for admission to the hospital. 4. Record daily weight for review by the healthcare provider at the next visit.

1. Notify the clinic if any vision changes are experienced. With the onset of pre-eclampsia, central nervous system changes may occur due to vasospasms and cerebral edema, resulting in headaches and visual disturbances (A). Although (B, C, and D) should be reviewed with the client, the early signs of toxemia of pregnancy should be emphasized.

After repeating the vital signs for a newborn who is 4 hours old, the practical nurse (PN) obtains an axillary temperature of 97.2 F and places the newborn under a radiant heat warmer. Which additional finding should the PN observe in the newborn? 1. Tremors of the hands during crying. 2. An increase in heart rate. 3. Flushing of the skin. 4. Respiratory depression.

1. Termors of the hands during crying. Placing a newborn under a radiant heat warmer with a temperature that persists below 98 F minimizes further manifestations of cold stress, which in the newborn causes an increase in glucose utilization resulting in hypoglycemia. An early indicator of cold stress is the presence of tremors of the hands, arms, and lips when the newborn cries (A). (B and C) are objective indicators that the heat source is effective. Cold stress causes an increased respiratory rate, not (D).

A client who is 5 weeks pregnant calls the clinic to report that her home pregnancy test is positive. She asks what she should be concerned about during the weeks before her first visit. Which signs and symptoms should the practical nurse (PN) tell the client to report immediately to the healthcare provider? (Select all that apply.) 1. Vaginal bleeding. 2. Decreased libido. 3. Urinary frequency. 4. Membrane rupture. 5. Severe headaches.

1. Vaginal bleeding 4. Membrane rupture. 5. Severe headaches. Vaginal bleeding (A), rupture of membranes (D), and severe headaches (E) are signs and symptoms that indicate the client is at risk for premature onset of labor and should be reported immediately. (B and C) are common complaints of early pregnancy that do not increase the risk for complications in pregnancy.

Which finding for a 2-week-old infant should the practical nurse (PN) report to the healthcare provider? 1. Yellowish tinge around the eyes. 2. Peeling skin on the trunk. 3. Cool hands compared to body core. 4. Small pink patch on base of neck. 4. Small pink patch at base of the neck.

1. Yellowish tinge around the eyes. A 2-week old infant with a yellow tinged skin around the eyes may indicate jaundice and should be reported to the healthcare provider (A). (B and D) are expected findings. (C) is likely due to environmental exposure, and the infant should be covered with a blanket.

A mother who is preparing for discharge begins asking the practical nurse (PN) questions about bottle feeding her infant. What information should the PN reinforce? 1. Place leftover formula in the refrigerator for 24 hours only. 2. Burp the newborn periodically during the feeding. 3. Heat the bottle of formula in the microwave oven. 4. Add extra formula powder to increase the concentration.

2. Burp the newborn periodically during the feeding. Newborns often swallow air when bottle feeding, so the mother should burp the infant periodically during and after the feeding (B) to remove air from the stomach and minimize gas and colic. Leftover formula (A) should be discarded due to risk of spoilage and contamination by temperature changes caused by cold storage, warming of the formula, and the duration of feeding. Microwave ovens do not heat the formula evenly and should be avoided (C). (D) should not be used because the newborn's kidneys are unable to excrete the increase amounts of protein.

A 3-day old newborn who weighed 7 pounds, 8 ounces at birth is breast feeding and now weighs 6 pound and 15 ounces. Which action should the practical nurse take? 1. Provide supplemental formula feedings. 2. Document the weight loss. 3. Review admission assessment findings. 4. Maintain strict intake and output.

2. Document the weight loss. A 10% weight loss in the first 3 days after birth is normal and related to the loss of excess extracellular fluid and meconium. Documentation of the weight loss (B) is indicated to determine subsequent fluid and nutritional intake. (A, C, and D) are not necessary at this time.

A young adult female comes to the health clinic to confirm a positive home pregnancy test. After determining the client's last menstrual period (LMP) as August 5, what expected date of birth (EDB) should the practical nurse (PN)calculate? 1. April 29 2. May 12 3. July 1 4. July 12

2. May 12 Naegele's rule for calculation of EDB is determined by adding 7 days to the first day of the LMP and then subtracting 3 months, so (B) is the correct calculation. (A, C, and D) incorrectly apply Naegele's rule.

Which intervention should the practical nurse (PN) provide a neonate during hospitalization? 1. Provide play activities in the hospital room. 2. Offer the neonate a pacifier between feedings. 3. Assign the neonate to a room with other neonates. 4. Request that parents bring security object from home.

2. Offer the neonate to a room with other neonates. The neonate needs opportunities for nonnutritive sucking and oral stimulation using a pacifier (B). (A , C and D) are not indicated for a neonate.

The practical nurse (PN) places a newborn who is 4 hours old with an axillary temperature of 97.2 o F under the radiant heat warmer. Which rationale supports the PN's action? 1. Heat loss increases as the newborn stretches from a flexed position. 2. The newborn's thin layer of subcutaneous fat provides poor insulation. 3. The basal metabolic rate is higher in a neonate that an adult. 4. Neonatal body surface area allows for a slower rate of heat loss.

2. The newborn's thin layer of subcutaneous fat provides poor insulation. Newborns have a large body surface area (BSA) and a relatively thin layer of subcutaneous fat which provides poor insulation (B) and predisposes the newborn to thermoregulation difficulties. (A and C) may contribute to body heat loss, but ineffective thermoregulation in the newborn is due to a lack of subcutaneous fat. The newborn's BSA favors a more rapid heat loss, not (D), than what an adult experiences.

Which client should the practical nurse (PN) closely monitor for severe afterpains? 1. A mother who had oligohydramnios during the pregnancy. 2. A primiparous client who is bottle feeding. 3. A multigravida who is breastfeeding. 4. A primigravida who delivered a 5 pound 3 ounce infant.

3. A multigravida who is breastfeeding. After multiple deliveries, the over-distended uterus establishes tonicity during early involution by periodically relaxing and then vigorously contracting, which is also stimulated by breastfeeding which releases oxytocin and causes post-delivery uterine contractions. A multigravida client who is breastfeeding (C) is mostly likely to experience severe afterpains. Oligohydramnios (A) (low amount of amniotic fluid) and bottle feeding (B) do not place the client at risk for experiencing severe afterpains related to multiparity. A low-birth weight infant (D) does not over-distend the uterus during the pregnancy.

The mother asks the practical nurse (PN) what her infant may need if the phenylketonuria (PKU) test is positive. What type of treatment should the PN tell the mother will be required? 1. Blood transfusions. 2. Iron-enriched formula. 3. Lifelong dietary management. 4. Medications to prevent infection.

3. Lifelong dietary management PKU is a condition related to the infant's inability to utilize the amino acid, phenylalanine, which must be omitted or strictly minimized in the diet throughout life (C). (A, B, and D) are not indicated.

An infant who weighs 4550 grams is delivered using forceps-assisted vaginal delivery. What action is most important for the practical nurse (PN) to implement? 1. Palpate the clavicle for irregularity. 2.Place the infant to the mother's breast. 3.Monitor for signs of hypoglycemia. 4. Complete a gestational age assessment.

3. Monitor for signs of hypoglycemia. A newborn who weighs 4550 grams is considered large for gestational age, or macrosomic, which increases the risk for hypoglycemia, hypocalemia, and hyperbilirubinemia. Monitoring for signs of hypoglycemia (C), such as jitteriness, is the priority so early corrective action can be initiated to reduce CNS irritability. (A) is implemented to identify signs suggestive of a fractured clavicle, but the priority action is early detection of hypoglycemia. (B) is implemented to meet a basic need, but additional monitoring is required for a macrosomic newborn who is at risk for hypoglycemia. (D) provides data that supports the classification of an infant who is large for gestational age and at risk for hypoglycemia.

A primiparous client asks the practical nurse (PN) how much her newborn baby boy should sleep every day. What information should the PN provide? 1. A primiparous client asks the practical nurse (PN) how much her newborn baby boy should sleep every day. What information should the PN provide? 2. Keep the baby awake during the daytime so he sleeps through the night. 3. A newborn sleeps most of the day and gradually will have increasing periods of wakefulness. 4. Expect your baby to follow your sleep and wake patterns once you establish a pattern at home.

3. Newborn sleeps most of the day and gradually will have increasing periods of wakefulness. The first 6 weeks of life involve a steady decrease in the newborn's sleep time, beginning with approximately 17 hours of sleep a day that progresses to increasing periods of wakefulness (C) as the need for socializing appears. (A, B, and D) are not expectations for the normal sleep patterns of a newborn.

A client who took iron supplements during pregnancy delivers an infant by cesarean section. On the second postpartum day, the client reports having a constipated stool that is greenish-black in color. Which action should the practical nurse (PN) implement? 1. Collect a stool sample for guaiac testing. 2. Administer a prescribed rectal suppository. 3. Record color and consistency of the stool. 4. Report the complaints to the charge nurse. 4. Report the complaints to the charge nurse.

3. Record color and consistency of the stool. Iron supplements cause constipation and contribute to the dark green-black color in stool, which should be documented (C) as an expected finding. (A, B, and D) are not indicated at this time.

A multiparous client's membranes rupture after 8 hours of labor. Which action should the practical nurse implement at this time? 1. Notify the client's healthcare provider. 2. Prepare the client for imminent birth. 3. Document the characteristics of the fluid. 4. Assess the fetal heart rate (FHR) and pattern.

4. Assess the fetal heart rate (FHR) and pattern. Assessment of the FHR and pattern (D) evaluates the fetus for distress due to a possible prolapsed cord. There is no data to support (B) at this time. After assessing the FHR and the appearance of the amniotic fluid, the healthcare provider (A) should be notified of the findings. (C) is implemented after assessing maternal and fetal status.

The practical nurse (PN) is discussing aspects of newborn hygiene with the new parents as they prepare for discharge. Which information should the PN provide? 1. Cleanse the ears and nose with cotton-tipped swabs. 2. Wash the baby's head once a week. 3. Begin tub baths when the cord is dried. 4. Create a draft-free environment when bathing the baby.

4. Create a draft-free environment when bathing the baby. Bathing the newborn infant provides opportunities for cleansing and observing the baby's skin, promoting comfort, and family socializing. Creating a room that is draft-free (D) prevents excessive heat loss during bathing when the newborn's thermoregulatory mechanisms are still stabilizing in the first weeks of life. The ears and nose should be washed using a wash cloth, not (A). The scalp and head should be washed daily, not (B), to prevent scalp desquamation, or cradle cap. Tub baths should begin after the dried umbilical cord has fallen off and the site is healed (C).

A primigravida client who is at 39-weeks gestation arrives at the clinic and tells the practical nurse (PN) she is having contractions every 5 minutes. The healthcare provider determines she is dilated 3 cm and in early labor. What action should the practical nurse (PN) implement when the client groans with each contraction? 1. Assist the client to the bathroom to void. 2. Give a prescribed narcotic analgesic. 3. Document the maternal vital signs. 4. Demonstrate simple relaxation measures.

4. Demonstrate simple relaxation measures. The use of relaxation techniques (D) is a recommended and effective method of decreasing the perception of uterine contraction intensity in early labor. Ambulating the client to the bathroom to empty her bladder (A) should allow labor progression, but does not minimize her discomfort. (B) is not indicated at this time. Documentation of vital signs should be made (C), but relaxation techniques provide distraction in early labor and relief of discomfort.

The practical nurse (PN) palpates fundal height at the umbilicus of a multiparous client who has just given birth to an 8-pound boy when dark red blood comes from the client's vagina. What action is most important for the PN to implement? 1. Continue to massage the fundus until firm. 2. Obtain serial vital signs every 15 minutes. 3. Observe the perineum for hematoma formation. 4. Determine if clots have formed in the lochia.

4. Determine if clots have formed in the lochia. The uterine height after birth should be midway between the umbilicus and symphysis. The client's fundal height and dark red lochia indicates inadequate uterine contraction, so the fundus should be massaged until firm (B). (A, C, and D) should be implemented, but the priority action is to ensure the uterus is firm to minimize lochia flow.

Which medication is prescribed for the prevention of ophthalmia neonatorum? 1. Triple antibiotic ointment (Neosporin). 2. Natamycin (Natacyn). 3. Tobramycin (Tobrex). 4. Erythromycin (Ilotycin).

4. Erythromycin (Ilotycin). An ophthalmic erythromycin preparation, such as Ilotycin (D), is commonly prescribed immediately after delivery to prevent gonococcal ophthalmia neonatorum, as well as Chlamydia organism. Ophthalmic medications, such as (A, B, and C), are used in the treatment of eye infection, but are not indicated for ophthalmia neonatorum prophylaxis.

The practical nurse (PN) is assessing a client 2 hours after a vaginal delivery of a 7-pound 3-ounce newborn and determines the client's bladder is distended. Which additional finding should the PN report to the charge nurse? 1. Multiple straight catheterizations during labor. 2. Fundus is 3 cm below the umbilicus. 3. Inability to initiate the urinary stream. 4. Excessive bleeding on the perineal pad.

4. Excessive bleeding on the perineal pad. A distended bladder prevents the uterus from contracting normally in the immediate postpartum period and causes excessive bleeding (D), which should be reported to the charge nurse. Although (A) places the client at risk for an urinary tract infection, bleeding can lead to hypovolemia and should be reported. (B) is a normal finding after delivery, but other vaginal delivery complications can cause postpartum bleeding, which should be reported to the charge nurse. (C) indicates the need to assess the perineum for trauma to the urinary meatus, but excessive bleeding should be reported.

Which strategy should the practical nurse (PN) implement to prevent a puerperal infection for a client during the first postpartum week? 1. Administer prophylactic antibiotics. 2. Give mega-doses of vitamin C. 3. Provide perineal care and pad change every 2 hours. 4. Implement strict medical and aseptic technique.

4. Implement strict medical and aseptic technique. Puerperal infection is most often an ascending infection in the first postpartum week when uterine sinuses and endometrium are healing, so strict medical technique (D), including hand washing and surgical asepsis should be observed during care of the perineum. Mega-doses of vitamin C (B) do not prevent infection in the first postpartum week. Prophylactic antibiotics (A) are not a standard prescription in the prevention of puerperal infection in a healthy population. Perineal care and pad change should be done after voiding and defecation or if soiled, so a strict 2-hour schedule is not indicated (C).

A primigravida at 33-weeks gestation is admitted after being involved in a motor vehicle collision (MVC). The client has no complaints of abdominal pain and no evidence of vaginal bleeding. Which action should the practical nurse (PN) anticipate implementing for the client? 1. Transfer to a trauma unit. 2. Monitor a ruptured spleen. 3. Prepare for Cesarean section. 4. Obtain a biophysical profile.

4. Obtain a biophysical profile. Possible blunt trauma that may occur during a MVC to the gravid abdomen places the client at risk for placental abruption. A biophysical profile (D), which includes a fetal non-stress test and an ultrasound, is prescribed to determine fetal well-being. (A, B, and C) are not indicated at this time.