HESI RN: Maternity - Test Bank
A 38-week primigravida who works as a secretary and sits at a computer
for 8 hours each day tells the nurse that her feet have begun to swell.
Which instruction would be most effective in preventing pooling of blood
in the lower extremities? - ............ANSWER..........Move about every
hour
Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will
straighten out the pelvic veins and increase venous return.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-
weeks gestation in preterm labor. She is given 3 doses of terbutaline
sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions.
The nurse plans to monitor for which primary side effect of terbutaline
sulfate? - ............ANSWER..........Tachycardia and a feeling of
nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates
beta-adrenergic receptors in the uterine muscle to stop contractions. The
beta-adrenergic agonist properties of the drug may cause tachycardia,
increased cardiac output, restlessness, headache, and a feeling of
"nervousness".
,When do the anterior and posterior fontanels close?
- ............ANSWER..........anterior fontanel closes at 12 to 18 months and
the posterior by the end of the second month.
When assessing a client who is at 12-weeks gestation, the nurse
recommends that she and her husband consider attending childbirth
preparation classes. When is the best time for the couple to attend these
classes? - ............ANSWER..........30 weeks gestation
at 30 weeks gestation is closest (of the options) to the time parents would
be ready for such classes. Learning is facilitated by an interested pupil!
The couple is most interested in childbirth toward the end of the
pregnancy when they are psychologically ready for the termination of the
pregnancy, and the birth of their child is an immediate concern.
The nurse should encourage the laboring client to begin pushing when... -
............ANSWER..........the cervix is completely dilated.
Pushing begins with the second stage of labor, i.e., when the cervix is
completely dilated at 10 cm (C). If pushing begins before the cervix is
completely dilated the cervix can become edematous and may never
completely dilate, necessitating an operative delivery. Many
primigravida's begin active labor 100% effaced and then proceed to
dilate.
The nurse instructs a laboring client to use accelerated-blow breathing.
The client begins to complain of tingling fingers and dizziness. What
,action should the nurse take? - ............ANSWER..........Have the client
breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation (blowing off
too much carbon dioxide). Hyperventilation is treated by retaining carbon
dioxide. This can be facilitated by breathing into a paper bag or cupped
hands.
Twenty-four hours after admission to the newborn nursery, a full-term
male infant develops localized edema on the right side of his head. The
nurse knows that, in the newborn, an accumulation of blood between the
periosteum and skull which does not cross the suture line is a newborn
variation known as... - ............ANSWER..........a cephalohematoma,
caused by forceps trauma and may last up to 8 weeks.
Cephalohematoma, a slight abnormal variation of the newborn, usually
arises within the first 24 hours after delivery. Trauma from delivery
causes capillary bleeding between the periosteum and the skull.
When does the head return to its normal shape?
- ............ANSWER..........7-10 days
What did Nurse theorist Reva Rubin describe?
- ............ANSWER..........The initial postpartum period as the "taking-in
phase," which is characterized by maternal reliance on others to satisfy
the needs for comfort, rest, nourishment, and closeness to families and
the newborn.
, A couple, concerned because the woman has not been able to conceive, is
referred to a healthcare provider for a fertility workup and a
hysterosalpingography is scheduled. Which post procedure complaint
indicates that the fallopian tubes are patent?
- ............ANSWER..........Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub
diaphragmatic collection of peritoneal dye/gas.
Which nursing intervention is most helpful in relieving postpartum
uterine contractions or "afterpains?" - ............ANSWER..........Lying
prone with a pillow on the abdomen
Lying prone keeps the fundus contracted and is especially useful with
multiparas, who commonly experience afterpains due to lack of uterine
tone.
Which maternal behavior is the nurse most likely to see when a new
mother receives her infant for the first time?
- ............ANSWER..........Her arms and hands receive the infant and she
then traces the infant's profile with her fingertips.
Attachment/bonding theory indicates that most mothers will demonstrate
behaviors described in during the first visit with the newborn, which may
be at delivery or later.
A 38-week primigravida who works as a secretary and sits at a computer
for 8 hours each day tells the nurse that her feet have begun to swell.
Which instruction would be most effective in preventing pooling of blood
in the lower extremities? - ............ANSWER..........Move about every
hour
Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will
straighten out the pelvic veins and increase venous return.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-
weeks gestation in preterm labor. She is given 3 doses of terbutaline
sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions.
The nurse plans to monitor for which primary side effect of terbutaline
sulfate? - ............ANSWER..........Tachycardia and a feeling of
nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates
beta-adrenergic receptors in the uterine muscle to stop contractions. The
beta-adrenergic agonist properties of the drug may cause tachycardia,
increased cardiac output, restlessness, headache, and a feeling of
"nervousness".
,When do the anterior and posterior fontanels close?
- ............ANSWER..........anterior fontanel closes at 12 to 18 months and
the posterior by the end of the second month.
When assessing a client who is at 12-weeks gestation, the nurse
recommends that she and her husband consider attending childbirth
preparation classes. When is the best time for the couple to attend these
classes? - ............ANSWER..........30 weeks gestation
at 30 weeks gestation is closest (of the options) to the time parents would
be ready for such classes. Learning is facilitated by an interested pupil!
The couple is most interested in childbirth toward the end of the
pregnancy when they are psychologically ready for the termination of the
pregnancy, and the birth of their child is an immediate concern.
The nurse should encourage the laboring client to begin pushing when... -
............ANSWER..........the cervix is completely dilated.
Pushing begins with the second stage of labor, i.e., when the cervix is
completely dilated at 10 cm (C). If pushing begins before the cervix is
completely dilated the cervix can become edematous and may never
completely dilate, necessitating an operative delivery. Many
primigravida's begin active labor 100% effaced and then proceed to
dilate.
The nurse instructs a laboring client to use accelerated-blow breathing.
The client begins to complain of tingling fingers and dizziness. What
,action should the nurse take? - ............ANSWER..........Have the client
breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation (blowing off
too much carbon dioxide). Hyperventilation is treated by retaining carbon
dioxide. This can be facilitated by breathing into a paper bag or cupped
hands.
Twenty-four hours after admission to the newborn nursery, a full-term
male infant develops localized edema on the right side of his head. The
nurse knows that, in the newborn, an accumulation of blood between the
periosteum and skull which does not cross the suture line is a newborn
variation known as... - ............ANSWER..........a cephalohematoma,
caused by forceps trauma and may last up to 8 weeks.
Cephalohematoma, a slight abnormal variation of the newborn, usually
arises within the first 24 hours after delivery. Trauma from delivery
causes capillary bleeding between the periosteum and the skull.
When does the head return to its normal shape?
- ............ANSWER..........7-10 days
What did Nurse theorist Reva Rubin describe?
- ............ANSWER..........The initial postpartum period as the "taking-in
phase," which is characterized by maternal reliance on others to satisfy
the needs for comfort, rest, nourishment, and closeness to families and
the newborn.
, A couple, concerned because the woman has not been able to conceive, is
referred to a healthcare provider for a fertility workup and a
hysterosalpingography is scheduled. Which post procedure complaint
indicates that the fallopian tubes are patent?
- ............ANSWER..........Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub
diaphragmatic collection of peritoneal dye/gas.
Which nursing intervention is most helpful in relieving postpartum
uterine contractions or "afterpains?" - ............ANSWER..........Lying
prone with a pillow on the abdomen
Lying prone keeps the fundus contracted and is especially useful with
multiparas, who commonly experience afterpains due to lack of uterine
tone.
Which maternal behavior is the nurse most likely to see when a new
mother receives her infant for the first time?
- ............ANSWER..........Her arms and hands receive the infant and she
then traces the infant's profile with her fingertips.
Attachment/bonding theory indicates that most mothers will demonstrate
behaviors described in during the first visit with the newborn, which may
be at delivery or later.
