HESI Practice Test - Maternity
A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education would be provided as soon as mom and baby are settled into their room? Select all that apply. One, some, or all responses may be correct.
"Wash your hands before touching the newborn." "All client identification bands should remain in place until discharge." "Place the newborn in the bassinet if you become sleepy." "Check the identification of staff, and if there is a question of validity, call the nursing station." Rationale: Washing hands before touching the newborn will decrease the chance of infectious transfer of microorganisms to the newborn. Mothers, significant others, or persons of the mother's choice, and the infant must continue to wear identification bands during the entire hospital stay. These bands show which baby belongs to which mother. To prevent falls or drops, the mother should place the newborn in the bassinet in the supine position if she becomes sleepy. The mother should call the nursing station to verify any person appearing to be staff if she has any question about who the person is. Proper identification must be worn by staff at all times. Safety is the most important concern. Individuals with infectious conditions are allowed to visit, but should not contact the newborn or should take special precautions. It is not necessary to send the newborn to the nursery during the night; the mother may keep the baby at her side during this time. There may be times when procedures, assessments, showering, and other activities involve the newborn being taken from the mother's room. Only well-identified staff members caring for the client should be allowed to take the infant out of the mother's sight. Bed sharing is not a safe sleep practice and the mother should be made aware of the associated risks.
A client notes a yellowish green vaginal discharge 4 days after a vaginal hysterectomy. Which additional clinical manifestation would the nurse expect if pelvic infection is present? Select all that apply. One, some, or all responses may be correct.
Abdominal pain Rising temperature Rationale: One characteristic of pelvic infection is abdominal pain. A rising temperature is a sign of infection. Shortness of breath may indicate a pulmonary embolism, but not pelvic infection. Urinary frequency is associated with cystitis, not a pelvic infection. 950 mL of urine in 24 hours is greater than the minimal 30 ml/hr of urine and would not be a point of concern. An increase, not decrease, in pulse rate would be expected with infection. The nurse will be concerned if perineal bleeding exceeds saturation of more than one pad per hour. Blood pressure would decrease if overwhelming sepsis were present.
Which presumptive sign of pregnancy will the nurse expect to find when assessing a client at 10 weeks' gestation? Select all that apply. One, some, or all responses may be correct.
Amenorrhea Breast Changes Urinary frequency Nausea Rationale: The key to answering this question is understanding the difference between presumptive versus probable signs of pregnancy. Presumptive signs of pregnancy are less specific subjective changes that are reported by the client during an assessment interview. The absence of menstruation (amenorrhea) is a presumptive sign of pregnancy that is recognized at 4 weeks' gestation. Breast changes, related to increased levels of estrogen and progesterone, are a presumptive sign of pregnancy that is recognized at 3 to 4 weeks' gestation. Urinary frequency, related to pressure of the enlarging uterus on the urinary bladder, is a presumptive sign of pregnancy that is recognized at 6 to 12 weeks' gestation. Nausea is a subjective presumptive sign that presents between 4-14 weeks' gestation. Probable signs of pregnancy are more objective changes that can be measured in the reproductive organs during a physical assessment. Hegar's sign is indicated by a softening of the cervix, which appears bluish and engorged. Chadwick's sign is a bluish discoloration of the cervix, vagina, and labia, an early indicator of pregnancy denoting increased blood flow to the reproductive organs. Abdominal enlargement related to the enlarging uterus is a probable sign of pregnancy that is recognized when the enlarging uterus rises out of the pelvis at 14 to 16 weeks' gestation. Headaches are not a symptom associated with pregnancy and are not considered a presumptive or probable sign.
Which newborn physical assessment finding will the nurse immediately report to the healthcare provider? Select all that apply. One, some, or all responses may be correct.
An expiratory grunt A persistent heart rate of 180 or more Apneic episodes that last longer than 20 seconds Rationale: An expiratory grunt can indicate narrowing of the bronchi. A persistent heart rate of 180 beats/minute or more can occur in respiratory distress syndrome or pneumonia. Apneic episodes that last longer than 20 seconds are concerning and can arise in preterm infants, babies who are rapidly cooled or warmed, or in instances of central nervous system or blood glucose instability. The expected head circumference for a newborn is between 32.5 and 37.5 cms. Clenched fists are a normal position for the newborn hands. A heart rate of 80 to 100 beats/minute when sleeping is a normal variation. A heart murmur over the base or at the left sternal border in interspace 3 or 4 can may be heard until the infant is one-year-old when the foramen ovale is anatomically closed. It is an expected finding for a few large vessels to be clearly or indistinctly visible, or not visible at all, over the abdomen.
Which complication would the nurse monitor for in the infant born at 36 1/7 weeks' gestation? Select all that apply. One, some, or all responses may be correct.
Apnea Hyperbilirubinemia Feeding difficulties Temperature instability Hypoglycemia Rationale: Late-preterm infants are born between 34 0/7 weeks' and 36 6/7 weeks' gestation and are at increased risk for apnea, hyperbilirubinemia, feeding difficulties, temperature instability, and hypoglycemia. The late-preterm infant is not at risk for electrolyte imbalances including hypercalcemia, hyperkalemia or hyponatremia.
Which recommendation would the nurse make for a pregnant client experiencing nausea and vomiting? Select all that apply. One, some, or all responses may be correct.
Avoid an empty or excessively full stomach Drink real ginger ale or tea, or use real ginger in another recipe Try sucking on sour candies or smelling a citrus-scented food or product Eat crackers or vanilla wafers or drink a small amount of liquid before getting out of bed Eat carb-rich, low-fat meals throughout the day, such as toast, oatmeal, or noodle soup Locate pressure points to reduce nausea in the middle of the wrist and press firmly for 3 minutes Maintain a good posture Rationale: Avoiding complete emptying of the stomach or overfilling the stomach can help reduce bouts of nausea. The oft-repeated home remedy of ginger for nausea is based on fact and worth a try! Sucking on sour candy or even smelling something sour, such as a citrus-scented hand lotion, might help relieve queasiness. Eating a small, bland carbohydrate before rising in the morning cuts back on morning sickness for many expectant mothers. Small, carbohydrate-rich, low-fat meals spread throughout the day would help the mother avoid an empty stomach, which can cause nausea. There are pressure spots on the wrists that might help relieve nausea; alternatively, acupuncture from a trained Eastern medicine specialist might be a consideration. Maintenance of a good posture gives the stomach ample room to function effectively. The client should eat 5-6 small meals a day instead of three good sized meals.
A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which sign of postmaturity would the nurse identify? Select all that apply. One, some, or all responses may be correct.
Cracked and peeling skin Long scalp hair and fingernails Decreased subcutaneous fat Umbilical meconium staining Creases covering the neonate's full soles and palms Rationale: Dry, peeling skin is related to decreased vernix and prolonged immersion in amniotic fluid. Abundant scalp hair and long fingernails are characteristics of postmaturity. These findings are typically noted in a term newborn who is 2 to 3 weeks old. Postmature neonates often have decreased subcutaneous fat and meconium staining to the umbilicus, nails, and skin. Creases on the entire soles and palms are typical of postmaturity; preterm newborns have few sole and palm creases. A red, puffy appearance of the face and neck is not a sign of postmaturity; neonates born to diabetic mothers usually have this appearance. A sign of postmaturity in the neonate is the lack of lanugo. Vernix is found on a newborn at about 38 weeks' gestation and disappears after 40 weeks' gestation.
Which order would the nurse expect to receive for a client with mild preeclampsia and increasing blood pressure? Select all that apply. One, some, or all responses may be correct.
Daily weight Side-lying bed rest Monitor deep tendon reflexes Initiate seizure precautions Maintain non-stimulating environment Rationale: Rapid weight gain is a sign of increasing edema. One liter of fluid is equal to 2.2 lb. Maintaining bed rest promotes fluid shift from the interstitial spaces to the intravascular space, which enhances blood flow to the kidneys and uterus; the side-lying position promotes placental perfusion. Deep tendon reflexes should be monitored. Reflexes of +2 are indicative of mild preeclampsia; +4 indicates severe preeclampsia. Seizure precautions are a standard treatment of care for the client with preeclampsia. The environment should be non-stimulating, quiet, and with low lighting A 2 g/day sodium diet will deplete the circulating blood volume, limiting blood flow to the placenta. A moderate sodium intake (6 g or less) is permitted as long as the client is alert and has no nausea or indication of an impending seizure. There is no data indicating that a glucose tolerance test is needed, as this would relate to gestational diabetes, not preeclampsia. To avoid pulmonary edema, IV fluids should not exceed 125 ml/hr.
Which recommendation for relieving insomnia will the nurse suggest to a client with menopause? Select all that apply. One, some, or all responses may be correct.
Drink chamomile tea Avoid caffeine after dinner Restrict liquids in the evening Sprinkle lavender oil on a pillow Use the bed for sleeping and sex only Rationale: Insomnia is common during menopause.
Which risk factor associated with intrauterine device (IUD) use would the nurse include in the discussion of an IUD with a client? Select all that apply. One, some, or all responses may be correct.
Expulsion of the device Risk for infection during insertion Risk for perforation of the uterus Ectopic pregnancy Rationale: Risks of IUD use include possible expulsion of the device, small risk for infection, and perforation of the uterus during insertion. If the client becomes pregnant while the IUD is inserted, an ultrasound will be needed to rule out ectopic pregnancy. Symptoms such as shortness of breath, chest pain, and severe leg pain are cardiovascular complications associated with oral contraceptives that may indicate a clot-related problem. An IUD is not associated with a delay of return to fertility nor an increased number of vaginal yeast infections.
Which alternative remedy would the nurse suggest to a client with dysmenorrhea who is interested in treating the condition with herbal therapies? Select all that apply. One, some, or all responses may be correct.
Ginger Fennel Valerian Wild Yam Black Haw Rationale: Herbal therapies used to treat dysmenorrhea include ginger, fennel, valerian, wild yam, and black haw. Ginger has anti-inflammatory effects. Fennel is a uterotonic. Valerian, wild yam, and black haw all have uterine antispasmodic effects. Broom flower, dong quai, and peony can cause uterine contractions.
The nurse is assessing a pregnant 16-year-old client. Which factor associated with adolescent pregnancy would the nurse consider when developing a plan of care for this client? Select all that apply. One, some, or all responses may be correct.
Higher rate of postpartum depression Inappropriate dietary choices Higher rate of anemia Incomplete bone mass Rationale: Adolescents have higher rates of postpartum depression than older women. An important aspect of nursing care for pregnant adolescents is to engage with them during the pregnancy and provide a supportive, welcoming environment and to develop a network of community resources supportive of pregnant and parenting teens to address their psychosocial issues. Adolescents may have inadequate diets and eat more fast foods. The diet is generally high in fats and carbohydrates and deficient in protein, calcium, fruits, and vegetables. Anemia is more common in teens and intensive nutrition evaluation and counseling is indicated. Peak bone mass is reached in the late teens or early 20s. When a teen is pregnant, higher levels of calcium are required to both provide support for the pregnancy and to support the teen's own bone health. An increased risk of gestational diabetes, mortality, and infantile chromosomal abnormalities are associated with the client of advanced maternal age over 35-years-old. Secondary sex characteristics appear early and are complete by the end of puberty; if the adolescent is pregnant, she has completed puberty.
The nurse assessing a newborn suspects Down syndrome. Which characteristic supports this conclusion? Select all that apply. One, some, or all responses may be correct.
Hypotonia Absence of head control Hypermobility of joints Epicanthal eye folds Single transverse palmar crease Rationale: Hypotonia is typical of newborns with Down syndrome. Their muscle tone is flaccid; they have less control of the head than a healthy newborn does because of their weak muscles. The hips, knees, and ankles of the Down Syndrome client are typically hypermobile. Epicanthal eye folds give the newborn with Down syndrome the typical slant-eyed appearance The single crease across the palm of the hand is typical of newborns with Down syndrome. A high-pitched cry is characteristic of newborns with brain damage, cerebral irritability (opioid withdrawal), and cerebral edema (hydrocephaly). A strong, rigid flexion is a sign of CNS disorder, not Down Syndrome. Rocker-bottom feet are found in newborns with trisomy 18.
Which action will the nurse implement to enhance safety for a laboring client and fetus with a prolapsed cord? Select all that apply. One, some, or all responses may be correct.
Increasing the client's IV fluid drip rate Placing the client in extreme Trendelenburg position Administering O2 to the client via nonrebreather mask Immediately notifying the client's Obstetric HCP Quickly gloving the examining hand and inserting 2 fingers into the vagina to the cervix Rationale: The nurse would increase the client's existing intravenous drip rate; place the client in the extreme Trendelenburg position; and administer oxygen using a nonrebreather mask. To enhance safety for a laboring client and fetus experiencing cord prolapse, the nurse would immediately notify the obstetric health care provider, or ask a colleague to do so. Then, after gloving the examining hand, the nurse can insert two fingers into the vagina to the cervix to alleviate cord compression. The cord should be wrapped loosely in warm sterile saline if it protrudes from the vagina. A rolled towel can be placed under one of the client's hips to help relieve cord compression. If the client is fully dilated the nurse will prepare for immediate vaginal delivery; if the client is not dilated, they will prepare for a caesarean delivery.
The nurse caring for a pregnant client suspects intimate partner violence (IPV). Which assessment supports the concern? Select all that apply. One, some, or all responses may be correct.
Low fetal weight is noted on the ultrasound Injuries are noted to the breast and abdomen of the client Verbalizations indicating social isolation are noted during visits The partner answers questions that are asked of the women Several visits to the clinic have occurred over the past month Each prenatal visit the client reports generalized somatic symptoms Rationale: IPV, including physical and sexual abuse, increases the risk for low birth weight, which would be identified prior to birth as decreased growth on an ultrasound. During pregnancy, IPV may increase and partners may focus their assaults on the breasts, buttocks, and abdomen. Social isolation is a common finding with IPV. It is common for the abuser to control the conversation by answering for the client. Women who are battered are at risk for stress illnesses such as gastrointestinal distress and chest pain. They are also more likely to suffer from frequent headaches and depression and therefore may have more than the normal number of clinic visits. These types of somatic symptoms may be vague, generalized or nonspecific in nature. Control is a primary concern of the abuser, so it would be highly unlikely for him to leave the client alone with the care provider. The many questions a client may have regarding all aspects of her care are not related to the probability of intimate partner violence.
The nurse is obtaining a health history from a client with endometriosis. Which consequence can occur as a result of this disorder? Select all that apply. One, some, or all responses may be correct.
Metrorrhagia Impaired fertility Bowel strictures Voiding difficulties Dysmenorrhea Painful intercourse Rationale: Metrorrhagia is a possible complication; bleeding between periods is due to the bleeding of endometrial tissue outside the uterus. Impaired fertility may result from adhesions around the uterus that pull the uterus into a fixed, retroverted position. The excessive tissue in endometriosis may impinge on the colon and cause ribbonlike stools. The endometrial tissue may impinge on the bladder and ureters and cause voiding difficulties. The major symptoms of endometriosis involve pelvic pain, painful menstruation, and painful intercourse. Endometriosis does not cause menopause. Multiparity, or having borne more than one child, is not a consequence of endometriosis.
Which clinical condition concerns the nurse the most for an obstetrical client with heart disease? Select all that apply. One, some, or all responses may be correct.
Obesity Anemia Hypertension Emotional distress Rationale: Clinical conditions that increase the workload of the heart and the risk of cardiac decompensation would be of the most concern to the nurse, and can be reduced by appropriate treatment. Conditions such as obesity, anemia, hypertension, and emotional stress should be reduced. Down syndrome is not associated with cardiovascular disease. Seasonal allergies and degenerative joint disease do not increase the workload of the heart. Hypothyroidism is not a condition that increases the workload of the cardiovascular system; however, hyperthyroidism does.
A client with a large fetus is to have a pudendal block during the second stage of labor. Which education will the nurse plan to provide regarding the effectiveness of the block? Select all that apply. One, some, or all responses may be correct.
Perineal pain will not be felt The bearing-down reflex will be diminished Contraction-related pain continues Rationale: The pudendal block provides anesthesia to the perineal area, after which pain is not felt in the lower vagina, vulva, or perineum. Although the bearing-down reflex is diminished, muscle control is not affected, and the client is able to bear down with contractions. The block does not eliminate uterine pain caused by contractions. Contractions are not decreased by either rate or intensity as a result of the block. The block affects only the perineum, not the bladder. It does not influence the decision of whether an episiotomy is needed. Fetal heart rate and maternal hemodynamics are not affected by a pudendal block.
The health care provider prescribes a contraction stress test (CST) for a client at 33 weeks' gestation. Which maternal condition will the nurse identify as a contraindication? Select all that apply. One, some, or all responses may be correct.
Previous classic cesarean delivery Preterm labor Placenta previa Cervical insufficiency Premature rupture of membranes Rationale: Extensive uterine surgery or a previous classic cesarean delivery is a contraindication for the CST. The CST may trigger a preterm birth in a client who is in preterm labor or has a history of preterm births. With a placenta previa, the contractions caused by the CST can stimulate bleeding. The CST is also contraindicated with cervical insufficiency, as these clients are already at a higher risk of preterm birth. The CST might also trigger a preterm birth in a woman whose membranes have ruptured prematurely. The CST measures your baby's reaction to temporary drops in blood flow and oxygenation. With a diagnosis of hypertension, it will assess associated effects on the placental circulation and determine the response of the compromised fetus to labor. A spinal cord injury does not affect a client's ability or the development of the fetus, and would not be a contraindication for a CST. A biophysical profile test is used to assess the general health of the fetus, includes the use of ultrasound, and results a score of 0-10. A score of 8-10 is called reassuring and is a positive sign and a score of 4 or less requires additional testing.
Which medication would the nurse question if prescribed for a pregnant client? Select all that apply. One, some, or all responses may be correct.
Warfarin Phenytoin Isotretinoin Clavulanate Methotrexate Rationale: Some medications are not safe to take during pregnancy because of the adverse effects to the fetus and/or newborn. Warfarin, phenytoin, isotretinoin, clavulanate, and methotrexate are not safe during pregnancy. Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for pregnant clients with depression because they have few side effects and are relatively safe. Common SSRIs used for the treatment of depression during pregnancy include citalopram, fluoxetine, and sertraline.