HESI Maternity 2

A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?

12 to 16

The nurse is assisting in conducting a prenatal session with a group of expectant parents. Which comment related to female hormones made by a parent indicates the need for further teaching?

"Prolactin is the hormone responsible for the initiation of labor."

Normal respiratory rate for a newborn infant

30-60 breaths/min

5 weeks

A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?

Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client's history. Which of the following findings is a contraindication to administration of the medication?

A previous hypersensitivity reaction to immune globulin -Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-positive fetal blood cells in any way

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which informative statement would the nurse provide to the client?

An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as most likely the result of:

Anxiety & Support

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action would be to monitor which clinical parameter?

Blood glucose level

A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically expect to note in the newborn?

Bowel sounds heard over the chest

The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse would perform which action

Clap the hand or slap on the mattress.

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy?

Cramping with bright red spotting Lack of tenderness of the breast Increased right-side flank pain

The nurse is reinforcing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which information in the discussion?

Describing the appropriate amount of weight gain required during the pregnancy

A nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which of the following actions should the nurse perform in response to this observation

Documenting the finding

A nurse is changing the diaper of a 1-day-old full-term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that the appropriate action is:

Documenting the findings (normal findings)

A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to:

Encourage the intake of oral fluids

A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures?

I need to drink 2000 ml a day

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?

Impaired bowel motility related to pain medication and immobility

"Do you have sharp pain on the right or left side of your pelvis?"-Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain, which is fairly sharp, is felt on the right or left side of the pelvis.

Increased fibrin degradation products -DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Petechiae, oozing from injection sites, and hematuria are indicative of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and therefore prolonged times); and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. Fibrinogen and platelets are decreased, prothrombin and activated partial thromboplastin times are prolonged, and fibrin degradation products are increased

Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.)

Increased heartburn that is not relieved with doses of antacid Chronic headache that has been lingering for a week behind the client's eyes

A clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up?

Increased shortness of breath and bilateral crackles in the lungs

The nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. Which description explains the purpose of estrogen?

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

Back pain?

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

The nurse assigned to care for a client with mild preeclampsia would anticipate which specific nursing intervention for this client?

Monitoring fetal movement

A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to suspect DIC?

Nonreassuring fetal heart rate pattern

A nurse is monitoring a pregnant client with placental abruption. Which pattern on the fetal monitor indicates to the nurse that fetal tissue perfusion is adequate?

Normal FHR

A delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. In light of this finding, which nursing action is appropriate initially?

Notifying the physician

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears?

Now that you have taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today.

Treatment of circumcision

Place petroleum ointment around the glans with each diaper change and cleansing

A pregnant woman at 38 weeks' gestation arrives at the emergency department, reporting bright-red vaginal bleeding but denying pain. On the basis of this information, the nurse determines that the client may be experiencing:

Placenta Previa

A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of this observation?

Pressure on the fetal head during a contraction

A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant?

Prone (to prevent pressure on the sac until surgical repair can be performed)

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

Put the newborn to the breast immediatelyPutting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority. Option A is not necessary; the infant can be transported attached to the placenta. Option B is an important psychosocial need but does not have the priority of option D. Although the husband is an important part of family-centered care, he is not the most important concern at this time.

A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones would the nurse identify as present at this time? Select all that apply.

Sex recognizable Testes descend into scrotum Kidneys able to secrete urine

A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that:

She needs to get the vaccine after she gives birth

A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse:

Simultaneously provides pressure over the lower uterine segment

A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the following, if noted in the infant, would indicate that the criteria for early discharge have been met?

The infant has urinated. The infant has passed 1 stool. Vital signs are documented as normal. The infant has completed one successful feeding

The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic would be a part of the teaching plan for this class?

Travel precautions and use of shoulder seat belts

In providing initial care to the newborn following delivery, what is the nurse's priority action?

Turn the infant's head to the side.

The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which finding places the client at risk for preterm labor?

UTI

Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which of the following findings would the nurse expect to note?

Uterine tender to palpation

The nurse is gathering data from a pregnant client about physiological risk factors. The nurse would be sure to obtain which priority data?

Weight and height

The nursing instructor asks the nursing student to identify the reason that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. Which response indicates that the student understands the rationale of this physiological response?

increased blood volume

fetal heart rate (FHR)

110 and 160

A nurse assists the primary healthcare provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy?

1. Determining the fetal heart rate 2. Noting the quantity, color, and odor of the amniotic fluid 3. Taking the client's temperature, pulse, and blood pressure 4. Replacing soiled underpads from beneath the client's buttocks 5. Planning evaluation of the client for signs and symptoms of infection

A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse:

Apply pressure, fundus massage