HESI Maternity Section
The nurse is performing an initial intake assessment for a newly pregnant client. Which questions will the nurse include in the assessment? (Select all that apply.) "Do you have proof of your immunizations?" Were your periods regular at every 28 days?" Are you have any nausea at any time during the day?
"Do you have proof of your immunizations?" Were your periods regular at every 28 days?" Are you have any nausea at any time during the day?
The pregnant client at 28 weeks gestation complains to the nurse about hemorrhoid pain. What suggestions should the nurse offer the client? (SATA) "Find a soft pillow when you are sitting at your desk at work "Walk for 30 minutes at least twice a day." "Eat one cup of raspberries or a medium pear every day." Sitting in a warm sitz bath can bring comfort to hemorrhoid pain. increase in fluids and fiber intake can decrease he chances of constipation.
"Find a soft pillow when you are sitting at your desk at work "Walk for 30 minutes at least twice a day." "Eat one cup of raspberries or a medium pear every day." Sitting in a warm sitz bath can bring comfort to hemorrhoid pain. increase in fluids and fiber intake can decrease he chances of constipation.
The clinic nurse is reviewing signs of pre-term labor with a client at 28 weeks gestation. Which client statements indicate to the nurse further teaching is necessary? (Select all that apply.) "I expect the discharge from my vagina will change from thick to brown over the next two weeks.", The baby's movements will decrease and be almost still from here on out." I should expect low back pain and diarrhea as the baby grows
"I expect the discharge from my vagina will change from thick to brown over the next two weeks.", The baby's movements will decrease and be almost still from here on out." I should expect low back pain and diarrhea as the baby grows
Which client statement indicates to the nurse that the she understands her pre-pregnancy instructions? "I will take 400 mcg of folic acid daily
"I will take 400 mcg of folic acid daily
The laboring client requests an epidural placement for labor pain. The standing order is for 1000 mL of LR to infuse over 15 minutes prior to the placement of the epidural. The client asks, "How come I have to have so much fluid so fast?" What is the nurse's best response? "It is to help prevent low blood pressure."
"It is to help prevent low blood pressure."
A new mother asks the nurse, "How do I know that my baby is getting enough breast milk?" Which explanation is most appropriate? "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day."
"Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day."
The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign? 5
5
The clinic nurse is performing an assessment on a client who is 20 weeks gestation, which was confirmed by ultrasound. When performing the fundal height assessment, where will the nurse start palpating the abdomen? At the umbilicus. The uterus enlarges 1 cm per week after about 18 weeks of pregnancy, ± 2 cm. At 20 weeks the uterus should be around the umbilicus. By 38 weeks the uterus is at the xiphoid process.
At the umbilicus. The uterus enlarges 1 cm per week after about 18 weeks of pregnancy, ± 2 cm. At 20 weeks the uterus should be around the umbilicus. By 38 weeks the uterus is at the xiphoid process.
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the mother's teaching plan? Avoid alcohol within two hours before the next feeding.
Avoid alcohol within two hours before the next feeding
The labor and delivery nurse is providing care to a mother who has experienced a fetal demise in utero at 36 weeks' gestation. What will the nurse include in this client's plan of care? (Select all that apply.) Contact the hospital chaplain. Ask about the last fetal movements Ask about plans for labor pain management Ask the parents if they want to hold the baby after birth
Contact the hospital chaplain. Ask about the last fetal movements Ask about plans for labor pain management Ask the parents if they want to hold the baby after birth
When reviewing a prenatal record for a client at 32 weeks' gestation, the nurse notes that the client was recently diagnosed with chlamydia. What will the nurse include in the client's teaching plan? Call the clinic immediately if you feel any gush of fluid from your vagina. Call the clinic immediately if you have contractions every 5 minutes for an hour. Do not have sex for 7 days after you take your antibiotics.
Call the clinic immediately if you feel any gush of fluid from your vagina. Call the clinic immediately if you have contractions every 5 minutes for an hour. Do not have sex for 7 days after you take your antibiotics.
The labor and delivery nurse is providing care to a client at term with known cardiac disease. Which focused assessments will the nurse include in the client's plan of care? (Select all that apply.) Cough, Dyspnea, Chest pain
Cough, Dyspnea, Chest pain
During stage two of labor, what assessments must the labor nurse perform? (SATA) FHR before, during and after the contraction, Freq of contractions, duration of contractions and uterine tone between contractions.
FHR before, during and after the contraction, Freq of contractions, duration of contractions and uterine tone between contractions.
Be sure you can recognize all positions that may require a C-section delivery including a frank breech, a complete breech and a transverse lie.
Fetal lie is difficult to become test-ready on without using visual aids
The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? (SATA) Gonorrhea and Syphilis Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia
Gonorrhea and Syphilis Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia
The client at 20 weeks' gestation states to the nurse, "I feel dizzy when I go from a sitting to a standing position." What is the nurse's best response? Make sure you change positions slowly. Safety first changing positions slowly will allow for accommodations of blood volume when changing positions
Make sure you change positions slowly. Safety first changing positions slowly will allow for accommodations of blood volume when changing positions
The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn at home. The woman tells the nurse, "I don't know what is wrong. I love my baby, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing? Postpartum blues.
Postpartum blues
A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing action should be included in this infant's discharge teaching plan? Observe the parents applying a Pavlik harness
Observe the parents applying a Pavlik harness
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." What is the next nursing action? Provide assistance to the mother to begin breastfeeding as soon as possible after delivery
Provide assistance to the mother to begin breastfeeding as soon as possible after delivery
Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client? The client's investment in what is being taught
The client's investment in what is being taught
The nurse is assessing a client in labor and finds the fetus has a right sacrum anterior (RSA) position. In order to place the fetal heart transducer properly, the monitor should be placed in which of the following areas? SEE PHOTO A, B, C, D
The right sacrum anterior (RSA) position indicates the baby buttocks faces anteriorly and towards the mother's right side of the abdomen. If you're familiar with fetal lie positions before delivery, you recognize that RSA is a breech position. In breech presentations, fetal heart sounds are usually heard above the level of the umbilicus. The heartbeat is best heard over the baby's back. In this case, the back faces the front of the abdomen. Therefore, the nurse should place the fetal monitor within the right upper quadrant (A).
A client at 39 weeks' gestation overhears her health care provider say to the nurse, "Her Bishop score is 10." The client asks the nurse, "What does that mean?" What is the nurse's best response? Your cervix is ready for labor. The bishop score represents the cervical consistency, dilation, position and effacement.
Your cervix is ready for labor. The bishop score represents the cervical consistency, dilation, position and effacement.