RN 45 OB Practice HESI Quiz 1

The father of a newborn tells the nurse, "My son just died." How should the nurse respond? A. "I am sorry for your loss." B. "There is an angel in heaven." C. "I understand how you feel." D. "You can have other children."

"I am sorry for your loss." The nurse should acknowledge the loss with a simple but sincere comment, such as (A), which validates the experience and recognizes the feelings of the parents.

A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding? A. 2 ounces. B. 4 ounces. C. 1.5 ounces. D. 3.5 ounces.

3.5 ounces A newborn requires approximately 19 to 21 ounces of formula each day (six feedings per 24-hour period x 3.5 = 21). (B) may cause the infant to spit-up due to over-feeding.

The nurse on the postpartum unit receives report for 4 clients during change of shift. Which client should the nurse assess for risk of postpartum hemorrhage (PPH)? A. A primigravida who had a spontaneous birth of preterm twins. B. A multigravida who delivered a 8 pound 2 ounce infant after an 8-hour labor. C. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia. D. A primiparous client who had an emergency cesarean birth due to fetal distress.

A multiparous client receiving magnesium sulfate during induction for severe preeclampsia. Magnesium sulfate administration during labor acts as a smooth muscle relaxant and contributes to uterine relaxation and atony, which poses a risk for early PPH.

A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give? A. Apply ice to the breasts. B. Wear a loose-fitting bra. C. Run warm water on the breasts during a shower. D. Express small amounts of milk from the breasts.

Apply ice to the breasts. Since the baby is receiving bottled formula, suppression of breast milk production is desired. Ice applications to the breast cause vasoconstriction which reduces engorgement and provides topical pain relief. A well-fitted support bra or breast binder , not (B), should be recommended to reduce stimulation of the nipples and breast tissue, which often stimulates breast milk production and engorgement. Applying heat to the breast causes vasodilation and increased engorgement (C). Expressing milk from the breast will stimulate additional milk production (D) and contribute to engorgement.

The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement? A. Institute contact precautions. B. Obtain a rectal temperature. C. Assess for abdominal distention. D. Decrease the amount of the feeding.

Assess for abdominal distention. Etiological factors playing an important role in the development of necrotizing enterocolitis (NEC), a complication common in premature infants, include intestinal ischemia, colonization by pathogenic bacteria, and substrate (formula feeding) in the intestinal lumen. Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of NEC. Nursing responsibilities include measuring the abdomen and listening for bowel sounds.

A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first? A. Prepare the client for imminent birth. B. Assess the fetal heart rate and pattern. C. Document the characteristics of the fluid. D. Notify the client's primary healthcare provider.

Assess the fetal heart rate and pattern. The fetal heart rate and pattern should be assessed to determine compromise of fetal well-being caused by compression or prolapse of the umbilical cord. Although the characteristics of the amniotic fluid should be documented, assessment of fetal response to the SROM is the priority.

While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding? A. Molding. B. Hemangioma. C. Cephalohematoma. D. Caput succedaneum.

Caput succedaneum. Caput succedaneum (D) is characterized by swelling of the soft tissues of the scalp that extends across suture lines. Cephalohematoma (C) is an edematous area caused by extravasation of blood between the skull bone and periosteum and does not cross the suture lines, which differentiates it from caput succedaneum.

When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? A. Quiet the infant before counting the heart rate. B. Listen at the apex of the heart. C. Count the heart rate for at least one full minute. D. Palpate the umbilical cord.

Count the heart rate for at least one full minute. It is most important for the nurse to count the heart rate for at least one full minute (C) so that irregularities or murmurs can be detected.

The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome? A. Mother's age. B. Amount of insulin required prenatally. C. Degree of glycemic control during pregnancy. D. Number of years since diabetes was diagnosed.

Degree of glycemic control during pregnancy. Clients with tight glucose control and no blood vessel disease should have positive pregnancy outcomes

Which action is most important for the nurse to implement for a client at 36-weeks gestation who is admitted with vaginal bleeding? A. Monitor uterine contractions. B. Apply disposable pads under the client. C. Determine fetal heart rate and maternal vital signs. D. Obtain blood samples for hemoglobin hematocrit levels.

Determine fetal heart rate and maternal vital signs. The priority nursing action is assessment of the fetal heart rate and maternal vital signs (C) to evaluate the impact of blood loss in the mother and fetus.

A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to baseline before each contraction ends. What action should the nurse implement? A. Insert an internal monitor device. B. Change the woman's position. C. Discontinue the oxytocin infusion. D. Document the finding in the client record.

Document the finding in the client record. Early FHR decelerations are a normal finding during active labor that occurs due to fetal head compression, so the finding should be documented in the client record. Although the client's status should be monitored continuously, this is a reassuring FHR pattern, so (A, B, and C) are not indicated.

A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this information, what action should the nurse implement? A. Notify the client's healthcare provider. B. Bring the delivery table to the room. C. Prepare to administer an oxytocic. D. Document the findings in the client record.

Document the findings in the client record. This labor pattern indicates that the client is in the active phase of the first stage of labor and has a normal labor pattern, so the findings should be documented in the client's medical record.

The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37-weeks gestation. What nursing action should be implemented first? A. Provide tactile stimulation. B. Administer flow by 100% oxygen. C. Asses the functionality of the monitoring device. D. Evaluate the newborn's color and respirations.

Evaluate the newborn's color and respirations. Monitors are an effective method for continual appraisal of a neonate's respirations, but a visual assessment of the infant oxygenation and respiratory status (D) should be implemented first. If the infant is not breathing, then tactile stimulation (A) should be given for no longer than 10 to 15 seconds before initiating CPR. Oxygen should be administered or increased (B) after determining the neonate's respiratory status. If there is normal color and presence of respirations after assessment, then possible causes of a false alarm (C) should be investigated for mechanical malfunction of the device.

Which client finding should the nurse document as a positive sign of pregnancy? A. Last menstrual cycle occurred 2 months ago. B. A urine sample with a positive pregnancy test. C. Presence of Braxton Hicks contractions. D. Fetal heart tones (FHT) heard with a doppler.

Fetal heart tones (FHT) heard with a doppler. Fetal heart tones (D) are a positive sign of pregnancy because these signs are attributed to the presence of a fetus. (A) is a presumptive sign of pregnancy as described by the client. (B and C) are probable signs of pregnancy that are best evaluated by the healthcare provider.

The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? A. Give 10 liters of oxygen via face mask. B. Prepare for an emergency cesarean section. C. Continue to monitor the fetal heart rate pattern. D. Obtain an oral maternal temperature.

Give 10 liters of oxygen via face mask. Late decelerations occur when there is reduced placental and fetal perfusion. Administering oxygen increases the oxygen saturation in the blood thus increasing oxygen to the fetus. (B, C, and D) are inaccurate.

The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the Dinamap display. What action should the nurse implement? A. Obtain a serum glucose level. B. Give the infant medication for pain. C. Feed the newborn 1 ounce of formula. D. Request a genetic consultation.

Give the infant medication for pain. A cry face (or crying with the eyes squeezed or closed tightly), a rigid posture, and an increase in blood pressure are indicative of pain in the neonate, so analgesia should be given for pain. The symptoms of hypoglycemia are jitteriness and mottling. The signs of hunger include rooting, tongue extrusion and possibly crying. A high-pitched shrill cry is associated with neurologic and genetic anomalies.

What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? A. Maternal bradycardia. B. Hard, board-like abdomen. C. Decrease in fundal height. D. Decrease in abdominal pain.

Hard, board-like abdomen. Abruptio placenta causes concealed intrauterine hemorrhage when the placenta separates and its edges do not. The formation of a hematoma behind the placenta and subsequent infiltration of the blood manifests as a firm, board-like abdomen which should be reported immediately to the healthcare provider. As bleeding occurs, fetal oxygenation and maternal stability are compromised leading to fetal and maternal tachycardia, not bradycardia. With abruptio placenta, fundal height and abdominal pain increase, not decrease.

A client comes in to the clinic for her six week postpartum check up and complains that her left breast is eythematous and painful. The client asks, "Can I still breastfeed my baby?" What is the best response for the nurse to provide? A. Advise to stop breastfeeding until the infection clears. B. Inform the client to continue breastfeeding. C. Begin all feedings with the infected breast. D. Tell the client to pump then discard the milk from the affected breast.

Inform the client to continue breastfeeding. The client should be encouraged to continue breastfeeding because emptying the breast helps alleviate the pain and prevents abscess formation. (A, C, and D) are inaccurate instructions for a breastfeeding client with mastitis.

A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. What action should the nurse implement next? A. Recheck the client's vital signs. B. Notify the healthcare provider. C. Insert an indwelling urinary catheter. D. Massage the fundus in 30 minutes.

Notify the HCP. Treatment of excessive bleeding requires the collaboration of the healthcare provider. Based on the findings, the healthcare provider should be notified (B) for additional treatment.

A client at 35-weeks gestation visits the clinic for a prenatal check-up. Which complaint by the client warrants further assessment by the nurse? A. Periodic abdominal pain. B. Ankle edema in the afternoon. C. Backache with prolonged standing. D. Shortness of breath when climbing stairs.

Periodic abdominal pain. Abdominal pain (A) may indicate preterm labor or placental abnormalities, so specific information should be gathered about the intensity, location, and circumstances surrounding the pain. (B, C, and D) are expected findings at 35-weeks.

What action should the nurse implement with the family when an infant is born with anencephaly? A. Ensure that measures to facilitate the attachment process are offered. B. Prepare the family to explore ways to cope with the imminent death of the infant. C. Inform the family about multiple corrective surgical procedures that will be needed. D. Provide emotional support to facilitate the consideration of fetal organ donation.

Prepare the family to explore ways to cope with the imminent death of the infant. Anencephaly, a neural tube congenital malformation, is the incomplete embryological formation of both cerebral hemispheres, which often results in death due to respiratory failure. While comfort measures are provided, there is no resuscitation effort or successful treatment available, so the family should be prepared for the infant's imminent death and encouraged to explore ways to cope with the loss and express grief.

What action should the nurse implement to prevent conductive heat loss in a newborn? A. Place the infant under a radiant warming system. B. Put a blanket on the scale when weighing the infant. C. Dry the newborn with a warmed blanket. D. Position the crib away from the windows.

Put a blanket on the scale when weighing the infant. Placing a blanket on the scale (B) provides a barrier to prevent conductive heat loss when the infant's body comes in contact with a cooler solid surface. (A) prevents convection heat loss from the infant's body to the surrounding air. (C) prevents heat loss by evaporation when the infant's body cools as moisture present on the skin evaporates. (D) prevents radiant heat loss when the body loses heat to solid items that are not in contact with the body but are in close proximity.

The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What nursing action should be implemented? A. Place socks on infant. B. Elevate feet 15 degrees. C. Wrap feet loosely in prewarmed blanket. D. Report findings to the healthcare provider.

Report findings to the HCP. Vasoconstriction of peripheral vessels, which can seriously impair circulation, is triggered by arterial vasospasm caused by the presence of the catheter, the infusion of fluids, or the injection of medication. Blanching of the buttocks, genitalia, or the legs or feet is an indication of vasospasm and should be reported immediately to the healthcare provider (D). (A, B, and C) do not provide effective resolution of this potentially serious complications.

What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal? A. Play soft music and talk to soothe the infant. B. Administer chloral hydrate for sedation. C. Feed every 4 to 6 hours to allow extra rest. D. Swaddle the infant snugly and hold tightly.

Swaddle the infant snugly and hold tightly. An infant experiencing drug withdrawal should be swaddled, wrapped snugly, or placed in a "kangaroo pouch" to reduce self-stimulation behaviors and protect skin from abrasions that may occur due to muscular irritability.

A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? A. Amniocentesis. B. Ultrasonography. C. Chorionic villus sampling. D. Maternal serum alpha-fetoprotein.

Ultrasonography. Gestational age, fetal growth, and the status and position of the placenta are monitored by ultrasound.