HESI Promotions Exam 2
The school nurse is teaching a group of 16-year-old girls about the female reproductive system. One student asks how long after ovulation it is possible for conception to occur. The most accurate response by the nurse is based on the knowledge that an ovum is no longer viable after when?
24 hours
Thirty minutes after a client gives birth, the nurse palpates the client's uterus. It is relaxed and the lochia is excessive. What is the nurse's initial action?
Massage the uterus.
The nurse discusses the recommended weight gain during pregnancy with a newly pregnant client who is 5 ft 3 in (160 centimeters) tall and weighs 130 lb (57 kilograms). The nurse explains that with the recommended weight gain, at term the client should weigh how much?
150 LB
A laboring client experiences a spontaneous rupture of membranes. What is the nurse's priority?
Assessing the fetal heart rate
A couple interested in family planning asks the nurse about the cervical mucus method of preventing pregnancy. The nurse explains that with this method the couple must avoid intercourse when and a few days after the cervical mucus is what?
Clear and stretchable
What is the priority nursing intervention for a client who has just given birth to her fifth child?
Palpating her fundus frequently, because she is at increased risk for uterine atony
A client's membranes rupture during labor. The nurse immediately assesses the electronic fetal heart rate. Variable decelerations lasting more than 90 seconds, followed by bradycardia, are observed on the monitoring strip. Which physiologic finding does the nurse suspect is the cause of this abrupt change?
prolapsed cord
A nurse in the birthing unit is admitting a client whose membranes ruptured at home. How does the nurse know whether the client is in true labor?
Contractions occur every 5 to 10 minutes, the cervix is dilated 2 cm and 75% effaced, and dilation has increased to 3 cm in 2 hours.
The nurse is caring for an assignment of postpartum clients. Which factor puts a client at increased risk for postpartum hemorrhage?
Giving birth to a baby weighing 9 lb 8 oz
What is the focus of the nurse's anticipatory guidance during the first trimester of pregnancy?
Physical changes of pregnancy
What is the nurse's most critical assessment for a client with preeclampsia during the immediate postpartum period?
Vital signs
A primipara about to be discharged with her newborn asks the nurse many questions regarding infant care. What phase of maternal adjustment does this behavior illustrate?
Taking-hold
A nurse is assessing a postpartum client for signs of hemorrhage by evaluating the degree of perineal pad saturation. What other parameter can the nurse use to estimate blood loss in a postpartum client?
Time elapsed between pad changes
While palpating the fundus of a postpartum client the nurse identifies separation of the abdominal muscles. How should the nurse document this finding?
Diastasis recti
At a client's first prenatal visit, the nurse-midwife performs a pelvic examination. The nurse states that the client's cervix is bluish purple, which is known as the Chadwick sign. The client becomes concerned and asks whether something is wrong. What does the nurse respond with about this expected finding?
"It is caused by increased blood flow to the uterus during pregnancy."
A pregnant client tells the nurse that she thinks she has developed an allergy because her nose is often very congested and she has difficulty breathing. How should the nurse reply?
"That is an expected occurrence; the increased hormones are responsible for the congestion."
A postpartum client who was receiving an intravenous infusion of oxytocin to stimulate labor asks the nurse why it is not being discontinued now that the baby is born. How should the nurse respond?
"The contractions prevent excessive bleeding."
A client at 37 weeks' gestation gives birth to a healthy baby. While inspecting her newborn in the birthing room, the client becomes concerned and asks, "What's this sticky white stuff all over the baby?" How should the nurse respond?
"This is vernix. It helps protect the baby while it's in the uterus."
A nurse is caring for a postpartum client. Where does the nurse expect the fundus to be located if involution is progressing as expected 12 hours after birth?
1 cm above the umbilicus
The nurse is caring for a postpartum client who has chosen formula feeding. What should the nurse teach her regarding minimizing breast discomfort?
Apply covered ice packs to the breasts
In the second hour after a client gives birth, her uterus is found to be firm, above the level of the umbilicus, and to the right of midline. What is the appropriate nursing intervention at this time?
Assisting the client to the bathroom to empty her bladder
A primigravida at term is admitted to the birthing room in active labor. Later, when the client is dilated 8 cm, she tells the nurse that she has the urge to push. The nurse instructs her to pant-blow at this time because pushing can cause which of the following?
Cervical edema
A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next?
Changing the client's position
External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action?
Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends
A client in labor is receiving an oxytocin (Pitocin) infusion. Which intervention is a priority for the nurse when repetitive late decelerations of the fetal heart rate are observed?
Discontinue the oxytocin infusion.
A client has delivered her infant via cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day?
Encouraging frequent ambulation
What is the priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline?
Massaging the uterine fundus
A client is visiting the prenatal clinic for the first time. While giving the nursing history the client states that her last menstrual period started on June 10. What is her expected date of birth (EDB), according to Nägele's rule?
March 17
The nurse determines that a postpartum client is gravida 1, para 1. Her blood type is B negative, and her baby's blood type is O positive. What should the nurse include in the plan of care?
Obtaining a prescription for Rho (D) immune globulin
The nurse is assessing the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located?
One or two fingerbreadths below the umbilicus
A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/mm 3. (16 X 10 9/L) What is the next nursing action?
Placing the report in the client's record because this is an expected postpartum finding
A nurse is teaching a childbirth preparation class regarding the discomforts of labor. What is the greatest influence on the perception of pain for a woman in labor?
Tension of the patient (mom)
A client who is visiting the prenatal clinic for the first time has a serology test for toxoplasmosis. What information about the client's activities in the history indicates to the nurse that there is a need for this test?
The client cares for the neighbors cat
The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations?
Uteroplacental insufficiency
A client gives birth vaginally to an infant who weighs 8 lb, 13 oz (3997 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vagina and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain?
Vaginal hematoma
What is the measurement of the fundus (uterus) when it is at the level of the umbilicus?
around 22-24 weeks
An adolescent who gave birth one day ago confides to the nurse that she hopes that her baby will "be good" and sleep through the night. What should the nurse include in the plan of care in order to ensure that this mother is able to cope with the nighttime demands of a newborn?
explain the period or PURPLE crying. which is an example of a program used by many hospital nurses to educate parents on the patterns of infant crying methods to quiet the baby.
A nurse caring for a pregnant woman determines that she is engaging in the practice of pica. What is pica?
inedible items are being digested
After the client gives birth, her vital signs are temperature 99.3° F (37.4° C); pulse 80 beats/min, regular and strong; respirations 16/min, slow and even; and blood pressure 148/92 mm Hg. Which vital sign should the nurse check more frequently?
blood pressure
When teaching a client about using a diaphragm as a form of contraception, what instructions should the nurse provide about the diaphragm?
It should remain in place for at least 6 hours after intercourse.
