Maternity HESI Questions (2)

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. I should stay on the diabetic diet 2. I should perform glucose monitoring at home 3. I should avoid exercise 4. I should be aware of any infection and report signs of infection to the HCP as soon as possible.

3. I should avoid exercise because of the negative effects on insulin production

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. provide pain relief measures 2. prepare client for an amniotomy 3. promote ambulation q30min 4. monitor oxytocin infusion closely

1. provide pain relief

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1. What can I do for you? 2. Now you have an angel in heaven 3. Don't worry, there's nothing you could have done to prevent this from happening 4. We will see to it that you have an early discharge so you don't have to be reminded of this experience.

1. What can I do for you?

The nurse is monitoring a PP client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. changes in vital signs 2. signs of heavy bruising 3. complaints of intense pain 4. complaints of a tearing sensation

1. changes in vital signs

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the HCP? 1. urinary output has decreased 2. dependent edema has resolved 3. BP is at prenatal baseline 4. complaints of headache and blurry vision

1. complaints of headache and blurry vision

An ultra sound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the US indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. delivery of the fetus 2. strict I&O monitoring 3. complete bedrest for the rest of the pregnancy 4. weekly monitoring of coagulation studies until delivery

1. delivery of fetus

The nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting HIV? 1. history of IV drug use 2. significant other who is heterosexual 3. history of sexually transmitted infections 4. one sexual partner for the past 10 yrs

1. history of IV drug use

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. hypotonic 2. precipitous 3. hypertonic 4. preterm

1. hypotonic

The nurse is assessing a pregnant client with type 1 DM about her understanding regarding changing insulin needs during her pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. i need to increase my insulin during the first 3 months of pregnancy 2. my insulin dose will need to increase during the 2nd and 3rd trimesters 3. episodes of hypoglycemia are more likely in the first 3 months of pregnancy 4. insulin needs should return to normal 7-10 days after birth if i'm bottle-feeding

1. i need to increase my insulin during the first 3 months of pregnancy

The nurse is providing instructions to a pregnant client with HIV regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. you will need to bottle-feed your baby 2. you will need to feed your baby by NG tube 3. you will be able to breastfeed for 6 months and then will need to switch to bottle feeding 4. you will be able to breast-feed for 9 months and then will switch to bottle-feeding

1. you will need to bottle-feed your baby`

A pp client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. providing sitz baths 2. encouraging fluid intake 3. placing ice on the perineum 4. monitor Hgb and Hct levels

2. encourage fluid intake

The nurse in the pp unit is caring for a client who has just delivered a newborn infant following a pregnancy with with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. infection 2. hemorrhage 3. chronic HTN 4. disseminated intravascular coagulation

2. hemorrhage

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35 y.o primigravida 2. the client has a hx of cardiac disease 3. the client's hbg is 13.5 4. the client is a 20 y.o. primigravida of average wt and ht

2. hx of cardiac disease

The nurse is monitoring a client in the immediate PP period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. temp of 100.4 2. an increase in HR from 88 to 102 3. BP change from 130/88 to 124/80 4. increase in RR from 18 to 22

2. increase in HR

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the HCP's prescriptions and should questions which one? 1. prepare client for an US 2. obtain equipment for a manual pelvic exam 3.prepare to draw a Hgb and Hct blood sample 4. obtain equipment for external electronic FHR monitoring

2. manual pelvic examination

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. provide comfort measures 2. monitor FHR 3. change client's position frequently 4. keep significant other informed of progress of labor

2. monitor FHR

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1. Gently push the cord into the vagina 2. place the client in trendelenburg position 3. find the closest telephone and page the HCP stat 4. call the delivery room to notify staff that the client will be transported immediately

2. place the client in trendelenburg position

After a precipitous deliver, the nurse notes that the new mother is passive and only touches her newborn infant briefly wiht her fingertips. What should the nurse do to help the woman process the delivery? 1. encourage her to breastfeed soon after the birth 2. support her reaction to the newborn infant 3. tell the mother that it is important to hold her infant 4. document a complete account of the mother's reaction on the birth record

2. support her reaction to the newborn infant

The nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. soft abdomen 2. uterine tenderness 3. absence of abdominal pain 4. painless, bright red vaginal bleeding

2. uterine tenderness

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. record the findings 2. massage the fundus 3. notify the HCP 4. place the client in trendelenburg position

3. Notify the HCP

The nurse in a maternity unit is reviewing client records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation? 1. primigravida with mild preeclampsia 2. primigravida who delivered a 10lb infant 3hrs ago 3. gravida 2 who has just been diagnosed with dead fetus syndrome 4. gravida 4 who delivered 8hrs ago and has lost 500 mL of blood

3. a gravida 2 who has just been diagnosed with dead fetus syndrome

The pp nurse is assessing a client who delivered a healthy infant by C-sec for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if SVT were present? 1. paleness of calf 2. coolness of calf 3. enlarged, hardened veins 4. palpable dorsalis pedis pulses

3. enlarged, hardened veins

On assessment of a pp client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. elevate the client's legs 2. document the findings 3. massage fundus until it's firm 4. push on uterus to assist in expressing clots

3. massage fundus until it is firm

The nurse is reviewing the HCP's prescriptions for a client admitted for PROM. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. monitor FHR continuously 2. monitor maternal VS closely 3. perform a vaginal exam every shift 4. administer ampicillin 1g as an IV piggyback q6hrs

3. perform a vaginal exam every shift

The nurse is developing a plan of care for a PP client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. assess vital signs q4hrs 2. measure fundal ht q4hrs 3. prepare an ice pack for application to the area 4. inform the HCP of assessment findings

3. prepare an ice pack for application to the area

The nurse is performing an assessment on a pregnant client with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Englargement of breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding in gums, petechiae, and purpura

4. Evidence of bleeding in gums, petechiae, and purpura

The nurse is providing instructions about measures to prevent PP mastitis to a client who is breastfeeding her newborn. Which client statement would indicate a need for further instruction? 1. I should breastfeed q 2-3 hrs 2. I should change the breast pads frequently 3. I should wash my hands before breastfeeding 4. I should wash my nipples daily with soap and water

4. I should wash my nipples daily with soap and water

A client in a pp unit complains of sudden sharp cx pain and dyspnea. The nurse notes that the client is tachycardic and the RR is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. initiate an IV 2. assess BP 3. prepare to administer morphine sulfate 4. administer oxygen

4. administer oxygen

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a C-sec birth, what is the most important nursing action? 1. slow IV flow rate 2. place in high fowler's position 3. continue pitocin drip if infusing 4. administer O2

4. administer oxygen, 8-10 mL/min via face mask

The nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the info provided by the nurse? 1. i should increase my sodium intake during pregnancy 2. i should lower my blood volume by limiting fluids 3. i should maintain a low-cal diet to prevent weight gain 4. i should drink adequate fluids and increase intake of high fiber foods

4. i should drink adequate fluids and increase my intake of high-fiber foods

A pregnant client reports to a health care clinic, complaining of a loss of appetite, weight loss, and fatigue. After assessment of the client, TB is suspected. A sputum culture is obtained and identifies mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 1. therapeutic abortion is required 2. she will need to stay at home until treatment is completed 3. medication won't be started until after delivery of fetus 4. isoniazid plus rifampin will be required for 9 months

4. isoniazid plus rifampin is required for 9 months

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. primiparous client who delivered 4 hours ago 2. multiparous client who delivered 6 hours ago 3. primiparous client who delivered 6 hours ago and had epidural anesthesia 4. multiparous client who delivered a large baby after oxytocin induction

4. multiparous client who delivered a large baby after oxytocin induction

The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. maternal fatigue 2. coordinated uterine contractions 3. progressive changes in cervix 4. persistent nonreassuring FHR

4. persistent nonreassuring FHR

Discomforts of pregnancy

N&V, syncope, urinary frequency/urgency, breast tenderness, increased vaginal discharge, nasal stuffiness, fatigue, heartburn, varicose vein, headaches,

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply: Uterine rigidity, Uterine tenderness, severe abdominal pain, bright red vaginal bleeidng, soft relaxed nontender uterus, fundal height greater than expected

bright red vaginal bleeding, soft relaxed nontender uterus, fundal height greater than expected

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? select all that apply: proteinuria, hypertension, low-grade fever, generalized edema, increased pulse rate, increased respiratory rate

proteinuria, hypertension, generalized edema

The nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply: wear a supportive bra; rest during the acute phase; maintain a fluid intake of at least 3000 mL; continue to breast feed if the breasts are not too sore; take the prescribed antibiotics until the soreness subsides; avoid decompression of the breasts by breastfeeding or breast pump

wear a supportive bra; rest during acute phase; maintain a fluid intake of at least 3000 mL; continue to breastfeed if breasts aren't too sore