Maternity HESI Case Study Questions with answers,

Maternity HESI Case Study |\ |\ |\ |\




Questions with answers |\ |\




The nurse performs the first assessment upon the client's arrival to
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the postpartum unit. Where would the nurse expect to palpate the
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fundus?


a. 3 cm above the umbilicus.
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b. 1 cm above the umbilicus.
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c. To the right of the umbilicus.
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d. Midway between the umbilicus and the pubic bone. - CORRECT
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ANSWERS ✔✔b. 1 cm above the umbilicus. |\ |\ |\ |\ |\ |\




For the first 12 hours, the fundus should be 1 to 2 cm above the
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umbilicus


Fifteen minutes after the initial assessment, the nurse finds the
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client disoriented and lying on her back in a pool of vaginal blood,
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with the sheets beneath her saturated with blood.
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,Which action is most important for the nurse to implement
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immediately?


a. Take vital signs
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b. Massage the fundus
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c. Check the bladder
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d. Increase the IV rate - CORRECT ANSWERS ✔✔b. Massage the
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fundus.


Since a boggy fundus is the most likely reason for this client's
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hemorrhaging, massing the fundus is the most important |\ |\ |\ |\ |\ |\ |\ |\



intervention. The nurse should also call for assistance due to the
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amount of blood that has pooled under the client.
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what is the most likely reason a postpartum patient would be
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hemorrhaging? - CORRECT ANSWERS ✔✔uterine atony (a "boggy" |\ |\ |\ |\ |\ |\ |\



fundus)
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,What should be assessed immediately after fundus is massaged and
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nurse has called for help? - CORRECT ANSWERS ✔✔Assess for
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bladder distention |\




--> The client is 2 hours post-delivery with an IV infusion at 125
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mL/hour, which can contribute to diuresis. A distended bladder
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impedes uterine contraction and contributes to excessive bleeding.
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After the fundus is massaged, the bladder should be checked for
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distention.


When the nurse conducts a gestational age assessment, which
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findings may indicate postmaturity? (Select all that apply. One,
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some, or all options may be correct.)
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a. Testes descended, good rugae.
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b. Formed ears with instant recall.
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c. Peeling, parchment-like skin.
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d. Thin with loose skin and little subcutaneous fat.
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, e. Deep creases at the base of the toes extending to the heels. -
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CORRECT ANSWERS ✔✔c. d. and e. |\ |\ |\ |\ |\ |\




c. Peeling, parchment-like skin.
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d. Thin with loose skin and little subcutaneous fat.
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--> Subcutaneous fat, which had been used for nourishment, is lost
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prior to birth. This results in the infant's low temperature.
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e. Deep creases at the base of the toes extending to the heels.
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--> Postterm infants develop deep creases on the feet, extending
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from the base |\ |\




The infant has a reddish papular rash across his face. How should
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the nurse respond when the client asks about the rash?
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a. Don't worry about it. This rash will go away in a couple of days.
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