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HESI Maternity Questions & Answers Already Graded A

HESI Maternity Questions & Answers 1. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. · Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 · Ampicillin 1 gram IV push q8h. · Betamethasone (Celestone) 12 mg deep IM · Butorphanol (Stadol) 1 mg IV push q2h PRN pain 2. A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? · Carrots · Chicken · Yogurt · Cheese 3. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? · Respiratory rate of 22 breaths/min · A large amount of lochia rubra · Blood pressure 149/90 · Positive Homan’s sign 4. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? · Pain level · Blood pressure · Infusion site · Contraction pattern 5. One day after vaginal delivery of a full term baby, a postpartum client’s white blood cell count is 15.000/mm. What action should the nurse take first? · Check the differential, since the WBC is normal for this client · Assess the client’s temperature, pulse, and respirations q4h · Assess the client’s perineal area for signs of a perineal hematoma · Notify the healthcare provider, since this finding is indicative of infection 6. A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? · Discuss the need for cortisol and aldosterone replacement therapy after discharge · Support the parents in their decision to assign sex of their child according to their preference · Offer information about ultrasonography and genotyping to determine sex assignment · Explain that corrective surgical procedures consistent with sex assignment can be delayed 7. A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer? 13 8. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? · Alert the neonatal team and prepare for neonatal resuscitation · Notify the healthcare provider from the client’s bedside · Obtain written consent for an emergency cesarean section · Draw a blood sample for stat hemoglobin and hematocrit 9. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? · Turn the client to her left side · Contact the healthcare provider · Assess the fetal heart rate · Check the cervical dilation 10. A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2-station. What action should the nurse implement first? · Decrease the oxytocin infusion rate · Determine current cervical dilation · Request placement of the epidural · Give a bolus of intravenous fluids 11. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the condition, what information is most important for the nurse to provide? Maternal blood pressure 12. A new mother is having trouble breast feeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother? Ask the mother to stop feeding, confront the infant, and then assist the mother to help the baby latch on. 13. The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client’s teaching plan? A. Oral contraceptive use for at least one year. 14. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? C. Betamethasone (Celestone) 12 mg deep IM. 15. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this fiding? B. Both the lower uterine segment and the fundus must be massaged. 16. A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet? B. Chicken. 17. The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer? 0.3 18 . The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? C. Blood pressure 149/90. 19. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time? D. Contractions decrease with walking. 20 . A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? D. Stimulate the infant to cry. 21. At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client? D. Early postpartum, within 72 hours of delivery. 22. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? D. Contraction pattern. 23. One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first? A. Check the differential, since the WBC is normal for this client. 24. A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client’s condition, what information is most important for the nurse to provide? A. Maternal blood pressure. 25. A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? C. Offer information about ultrasonography and genotyping to determine sex assignment. C. Take the child to a hair salon for a shampoo and a shorter haircut. D. Dispose of the child’s brusches, combs, and others hair accessories. 26. During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client. D. Elevate the head with two pillows while sleeping. 27 . The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement? A. Document the vital signs in the record. 28. A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide? C. Apply hot packs just before each feeding. 29. A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only) 13 30. A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first? A. Place the infant on the abdomen to protect the sac. 31. The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son’s acne cream, benzoyl peroxide, on the baby’s face. Which answer should the nurse to provide? A. “ Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider” 31. The nurse is providing preoperative teaching to a teenaged client with appendicitis information should the nurse include about postoperative activity? D. Early ambulation after surgery will be encouraged to reduce complications and promote healing. 32. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? C. obtain written consent for an emergency cesarean section. 33. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? B. Contact the healthcare provider. 34. A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer’s Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only) 75 35. Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority? D. Have a meconium aspirator available at delivery. 36. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first? B. Determine current cervical dilation. 37. A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant’s skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)? A. Sweat-chloride test. 38. A client with gestational diabetes is undergoing a non-stress test (NST) at 34-weeks gestation. The baseline fetal heart rate (FHR) is 144 beats/minute. The client is instructed to mark the fetal monitor paper by pressing a button attached to the fetal monitor each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. Which outcome indicates a reactive NST? C. Two FHR accelerations of 15 beats/minute x 15 seconds are recorded. 39. A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform? B. Babinski’s reflex. 40. The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life? C. Cries vigorously when stimulated. 41. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis af eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan? C. Monitor Blood pressure, pulse, and respirations q4h. 42. What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes? A. Restrict carbohydrate intake. 43. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother? B. Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby lactch on. 44. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.) A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. E. Has a disheveled appearance. 1-IV MAT ml/hr. 12.5 2-Women in the bathroom who has delivery at the bathroom. The nurse call for help. 15- The nurse is teaching a new mother about breast feeding. The client tell the nurse that her sister become very uncomfortable when she tries to breast feeding because she had too much milk What suggestion should the nurse provide to help this client complains with the discomfort associated with engorged breast ? ANSWER / Wear a supportive bra at all time. 16- A 38 weeks primigravida is admitted in labor -delivery with a non – reactive result (NST).The nurse begins a contraction stress with oxytocin Pitocin infusion. Which finding is most important for the nurse to reporthealthprovider? ANSWER/ A pattern of fetal late decelerations 17- A 33 years old client gravida 7 para 5 is submitted to the hospital in emergency room at 32 weeks of gestation.She is not pain, is alert and is not acute distress FHR 120 BEATS/MINUTES with minim variability. She tells the nurse thatshe woke up to find that she was lyingin a pool a blood. Which assessment data should the nurse obtain first? Cervical dilation Maternal blood pressure Hematocrit and Hemoglobin Uterine Contraction ANSWER / Blood pressure 18- During the admission of a newborn, the nurse identifies alocalized swelling that does not cross the suture line on the posterior area of the parietal bone. What intervention the nurse implement? ANSWER Notification pediatrician of the cephalohematoma

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