HESI

A nurse is caring for a newborn immediately following birth. Which of the following is the highest priority action by the nurse at this time?

Performing the initial birth

a nursing is caring for a patient who is in the first stage of labor and is encouraging the patient to void every 2 hours. which of the following statement justifies the nurse's intervention

"A distended bladder reduces pelvic space needed for birth"

A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie?

Palpate the fundus of the uterus

A nurse is reviewing postpartum nutrition needs with a group of new mothers who are breastfeeding their newborn. Which of the following statements by one of the mothers indicates an understanding of the teaching?

"I will continue my calcium supplements because I don't like milk."

A patient who is 8 weeks pregnant tells the nurse that she is not happy about the pregnancy. Which of the following responses should the nurse take:

"It is normal to have these feelings during the first few month of pregnancy"

a nurse is caring for a patient in second stage of labor. The patient's significant order ask the nurse to explain how he will know when crowning occurs . Which of the following responses should the nurse make?

"The vaginal area will bulge as the baby's head appears."

A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly hired nurses. Which of the following statements by a nurse indicates understanding of the teaching?

"They are administered in an oral form."

A nurse in a prenatal clinic is teaching a pregnant patient about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching?

"You should empty your bladder prior to the procedure"

a nurse in a clinic is caring for a post operative patient following a salpingectomy due to an ectopic pregnancy. which statement. by the client requires clarification?

"it is good to know that I won't have a tubal pregnancy in the future"

A nurse is providing discharge instructions for a patient. At 4 weeks postpartum, the patient should contact her provider for which of the following findings?

"sore nipples with cracks and fissures"

A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish marking across the newborn's lower back. The nurse should include and document which of the following information in the teaching?

"this is frequently seen in newborn who have dark skin"

Math

0.29

A patient is diagnosed with a sexually transmitted infection. The physician orders Penicillin 1,200,000 units

2.4

the nursing is caring a postpartum client who is bleeding excessively . the nurse is about to weight the pad she just removed from the client. the pad weighs 275 grams. what is the blood loss in milliliters?

255ml

a nurse in a prenatal clinic is caring for four pregnant patients.. which of the following patient's weight gain should the nurse report to the provider?

3.6 kg (8lb) weight gain and is in her first trimester

a maternity nurse is performing a fundal assessment for a patient who is 2 days postpartum and observes the perineal pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small cloths. which of the following findings should the nurse document?

A moderate lochia rubra

which intrapartum assessment should be avoided when caring for a patient with HELLP syndrome?

Abdominal palpations

A nurse is caring for a patient in labor. Her vaginal exam 2 hrs ago revealed cervix 3 cm, dilated, 100% effaced, -2 station with membranes intact. The patient suddenly states "My water broke." The monitor reveals a FHR of 80 to 85 b/min, and the nurse performs a vaginal exam noticing clear fluid and a pulsating loop of umbilical cord in the patient's vagina. Which of the following priority action should the nurse perform

Administer oxygen at 10L/min via a face mask

Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy?

Administration of methotrexate

A pregnant patient presents to labor and delivery with a positive Group B Streptococcus (GBS) result. The woman wants to know about this infection. What information about GBS is correct?

Antibiotic will be administered during labor before vaginal delivery to prevent the neonate from getting infection

A patient with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a

Anticonvulsant

a nurse report is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make?

Apply cold compress between feedings

The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse's next action?

Ask the patient when she last had anything to eat or drink.

a nurse is caring for a client who is pregnant and states that her last menstrual period was April 1st 2020. which of the following is the client's estimate date of delivery?

B - January 8, 2021

A maternity nurse is reviewing ways to prevent a TORCH infection during pregnancy with a group of new nurses. Which of the following statement made by a nurse indicates understanding of the teaching?

B - a woman should avoid eating undercooked meat during pregnancy or C - a woman should avoid crowded places during pregnancy

Baby weighs 4,000 grams at birth and is admitted for dehydration. the baby now weighs 3.746 grams. Calculate the percentage weight

B 6.35%

a nurse is teaching a patient who is breastfeeding and has mastitis. Which of the following responses should the nurse make?

Completely empty each breast at each feeding or use a pump

A labor and delivery nurse is planning care for a newly admitted patient who reports that she is in labor and has had vaginal bleeding for 2 weeks. Which of the following should the nurse include in her plan of care?

Defer vaginal examination

A maternity nurse is caring for a postpartum patient. The nurse is assessing for maternal adaptation and mother infant bonding. Which of the following behaviors by the patient indicates the need for the nurse to intervene? SATA

Demonstrates apathy when the infant cries.Views the infant's behavior as uncooperative during diaper changing

which routine nursing assessment is contraindicated for a patient admitted with suspected placenta previa?

Determining cervical dilation and effacement

Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication

Drowsiness

a nurse is caring for a labor patient who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter placed to monitor uterine contraction. For which of the following contraction patterns should the nurse discontinue the infusion?

Duration of 90 to 120 seconds

a nurse is reviwing contraindications for circumsion with a student nurse. which of the following conditions are contraindicated for this procedure?

Epispadias family history of hemophilia hypospadias

a nurse is completing a newborn assessment and observes small white nodules on the roof the newborn's mouth. this finding is a characteristic of which of the following conditions?

Epstein pearls

A nurse is admitting a client who is in labor and has hiv. which of the following intervention should the nurse identify as contraindicated for this client?

Forceps delivery Internal fetal monitoring Episiotomy

a maternity nurse is caring for a patient who is in active labor and reports sever back pain. During assessment the fetus is noted to be in the occipital posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor process

Hands and knees

A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following?

Hemorrhage is the primary concern.

A nurse is assessing the reflexes of a newborn in checking for the moro reflex, the nurse should perform which of the following?

Hold the newborn in a semi-sitting position, then allow the head and trunck to fall backwards

A maternity nurse is caring for a pregnant patient who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing

Hyperglycemia meconium aspiration

A nurse is reviewing car seat safety with the parents of a newborn. Which of the following statement if made by the patent indicates further teaching is required regarding car seats safety?

I will place the infant in the front seat forward-facing

A cesearean section client who was diagnoses gestational hypertension in the labor is transferred to the postpartum unit post delivery. upon revewing the orders by the postpartum nurse, which prescription should the nurse clarify?

Ibuprofen

A nurse is teaching a 16 year old about contraception. What statement by the client indicate need for further teaching? SATA

If I take my birth control pill every other day at 4pm, it is guaranteed to work I cannot get pregnant if my partner pulls out Using spermicide during intercourse will guarantee that I will not get pregnant or sexually transmitted infections

which instructions should the nurse include when teaching a pregnant patient with Class 2 heart disease?

Inform her of the need to limit fluid intake

A nurse caring for a pregnant patient that is undergoing a non stress test. The patient asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make?

It awakens a sleepy fetus

a nurse is reviewing care of the umbilical chord with the parent of a newborn. which of the following instruction should the nurse include in her teaching?

Keep the diaper folded below the cord

a nurse is teaching a group of new parents about proper technique for bottle feeding. which of the following instruction should the nurse provide?

Keep the nipple full of formula throughout the feeding

a nurse is caring a patient who is preterm labor and is scheduled to undergo an amniocentesis. the nurse should evaluate which of the following tests to assess fetal lung maturity?

Lecithin/spingomyelin (L/S) ration

A nurse is taking a newborn to a mother following circumcision. Which of the following actions should the nurse take for security purposes?

Match the mother's identification band with the newborn's band

A client who is 38 weeks gestation comes to the clinic for routine examination. the nurse is preparing discharge teaching for this client. What is the priority teaching for this client in 38 weeks gestation?

Maternal nutrition

A nurse in the postpartum unit is planning care for a patient who has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care?

Measure leg circumference

A nurse is interviewing a pregnant patient during a prenatal visit. Which patient statement might suggest a need to evaluate further for preeclampsia?

My work shoes don't fit me any more

A nurse is caring for a preterm newborn with respiratory distress syndrome. which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant?

Oxygen saturation

A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. Which of the following information should the nurse include in the teaching? (SATA)

Place used bottles in the dishwater Check the nipple for appropriate flow of formula Use tap water to dilute concentrated formula

a nurse is assessing a postpartum patient who is exhibiting tearfulness, insomnia, lack of appetite and a feeling of letdown. which of the following conditions are associated with these clinical findings ?

Postpartum blues

A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (SATA)

Precipitous delivery Inversion of the uterus Retained placental fragments

a maternity nurse caring for a patient in labor who is experiencing incomplete uterine relaxation. between hypertonic contractions. the nurse should identify that this contraction pattern increases the risk for which of the following complications?

Reduced fetal oxygen supply

A nurse is caring for a patient diagnosed with ruptured ectopic pregnancy. Which of the following finding is seen with this condition?

Report of severe shoulder pain

A nurse is administering magnesium sulfate IV to a client who has severe pre-eclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (SATA)

Respirations less than 12/min Urinary output less than 30mL/hr Decreased level of consciousness

A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following?

Shortness of Breath (SOB)

A nursing is caring for an infant with hyperbilirubinemia and is receiving phototherapy. which of the following is a priority finding in the newborn?

Sunken fontanels

A nurse is teaching a newly license nurse about neonate abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching?

The newborn will have a continuous high-pitched cry

A nurse is caring for a pregnant patient with suspected hyperemesis gravidarum and is reviewing the laboratory reports. Which of the following findings is a manifestation of this condition?

Urine ketones present

a patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate:

Worsening disease and impending convulsion

During ambulation to the bathroom,, a one day postpartum section patient experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, at the midline and at the level of the umbilicus. How should the nurse interpret this data?

a normal postural discharge of lochia

a nurse is caring for a laboring patient who is using patterned breathing during labor. the patient reports numbness and tingling of the fingers. what priority intervention will the nurse perform first place?

an oxygen mask over the client's nose and mouth

a nurse is completing a newborn assessment. Which of the following data indicate the newborn is adapting to extrauterine life (SATA)

apnea for 10 second periods Obligatory nose breathing

a nurse is caring for a neonate born at 38 weeks gestation, weighs 3200 g and in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following?

appropriate for gestational age

a nurse is caring for a patient who has postpartum psychosis. which of the following actions is the nurse's priority?

ask the patient if she has thought of harming herself or her infant

The priority nursing intervention when admitting a pregnant patient who has experienced a bleeding episode in late pregnancy is to?

assess fetal heart rate and maternal vital signs

a nurse is caring for a 1 hr postpartum patient following vaginal birth and experiencing uncontrollable shaking. the nurse should understand that shaking is due to which of following factors?

change in body fluid metabolic efforts of labor

A nurse is caring for a patient in labor who is receiving oxytocin for induction of labor with an intrauterine pressure catheter placed to monitor uterine contractions. For which of the following uterine contraction patterns should the nurse discontinue the infusion of oxytocin?

duration of 90 to 120 secs

A nurse in the labor and delivery unit is caring for patient in labor. The fetal heart rate is recorded 140 b/min. Contractions are occurring every 8 mins lasting 30 to 40 seconds. Vaginal exam revealed cervix 2 cm dilated, 50% effaced and -2 station. Which of the following stages and phases of labor is the patient experiencing?

first stage, active phase

A nurse is reviewing the health record of a pregnant patient. the provider indicated that the patient exhibits probably signs of pregnancy. Which of the following findings should the nurse expect?

goodell's sign ballotment chadwick's sign

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications is risk factor for this condition?

placenta previa