HESI MATERNITY 2 TEST BANK
Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?"
a. Lying prone with a pillow on the abdomen
b. Using a breast pump
c. Massaging the abdomen
d. Giving oxytocic medications
Lying prone (A) keeps the fundus contracted and is especially useful with multiparas,
who commonly experience afterpains due to lack of uterine tone.
A multigravida client arrives at the labor and delivery unit and tells the nurse that
her bag of water has broken. The nurse identifies the presence of meconium fluid
on the perineum and determines the fetal heart rate is between 140 to 150
beats/minute. What action should the nurse implement next?
a. Complete a sterile vaginal exam
b. Take maternal temperature every 2 hours
c. Prepare for an immediate cesarean birth
d. Obtain sterile suction equipment
A vaginal exam (A) should be performed after the rupture of membranes to determine
the presence of a prolapsed cord.
When explaining "postpartum blues" to a client who is 1 day postpartum, which
symptoms should the nurse include in the teaching plan? (Select all that apply.)
a. Mood swings
b. Panic attacks
c. Tearfulness
d. Decreased need for sleep
e. Disinterest in the infant
"Postpartum blues" is a common emotional response related to the rapid decrease in
placental hormones after delivery and include mood swings (A), tearfulness (C), feeling
low, emotional, and fatigued.
1
, HESI MATERNITY 2 TEST BANK
A client at 30-weeks gestation, complaining of pressure over the pubic area, is
admitted for observation. She is contracting irregularly and demonstrates
underlying uterine irritability. Vaginal examination reveals that her cervix is
closed, thick, and high. Based on these data, which intervention should the nurse
implement first?
a. Provide oral hydration
b. Have a complete blood count (CBC) drawn
c. Obtain a specimen for urine analysis
d. Place the client on strict bedrest
Obtaining a urine analysis (C) should be done first because preterm clients with uterine
irritability and contractions are often suffering from a urinary tract infection, and this
should be ruled out first.
A client in active labor complains of cramps in her leg. What intervention should
the nurse implement?
a. Ask the client if she takes a daily calcium tablet
b. Extend the leg and dorsiflex the foot
c. Lower the leg off the side of the bed
d. Elevate the leg above the heart
b. Extend the leg and dorsiflex the foot
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client
is capable) (B) and putting the heel of the foot on the floor is the best means of relieving
leg cramps.
The nurse is caring for a woman with a previously diagnosed heart disease who
is in the second stage of labor. Which assessment findings are of greatest
concern?
a. edema, basilar rales, and an irregular pulse
b. Increased urinary output, and tachycardia
c. Shortness of breath, bradycardia, and hypertension
d. Regular heart rate, and hypertension
Edema, basilar rales, and an irregular pulse (A) indicate cardiac decompensation and
require immediate intervention.
2
Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?"
a. Lying prone with a pillow on the abdomen
b. Using a breast pump
c. Massaging the abdomen
d. Giving oxytocic medications
Lying prone (A) keeps the fundus contracted and is especially useful with multiparas,
who commonly experience afterpains due to lack of uterine tone.
A multigravida client arrives at the labor and delivery unit and tells the nurse that
her bag of water has broken. The nurse identifies the presence of meconium fluid
on the perineum and determines the fetal heart rate is between 140 to 150
beats/minute. What action should the nurse implement next?
a. Complete a sterile vaginal exam
b. Take maternal temperature every 2 hours
c. Prepare for an immediate cesarean birth
d. Obtain sterile suction equipment
A vaginal exam (A) should be performed after the rupture of membranes to determine
the presence of a prolapsed cord.
When explaining "postpartum blues" to a client who is 1 day postpartum, which
symptoms should the nurse include in the teaching plan? (Select all that apply.)
a. Mood swings
b. Panic attacks
c. Tearfulness
d. Decreased need for sleep
e. Disinterest in the infant
"Postpartum blues" is a common emotional response related to the rapid decrease in
placental hormones after delivery and include mood swings (A), tearfulness (C), feeling
low, emotional, and fatigued.
1
, HESI MATERNITY 2 TEST BANK
A client at 30-weeks gestation, complaining of pressure over the pubic area, is
admitted for observation. She is contracting irregularly and demonstrates
underlying uterine irritability. Vaginal examination reveals that her cervix is
closed, thick, and high. Based on these data, which intervention should the nurse
implement first?
a. Provide oral hydration
b. Have a complete blood count (CBC) drawn
c. Obtain a specimen for urine analysis
d. Place the client on strict bedrest
Obtaining a urine analysis (C) should be done first because preterm clients with uterine
irritability and contractions are often suffering from a urinary tract infection, and this
should be ruled out first.
A client in active labor complains of cramps in her leg. What intervention should
the nurse implement?
a. Ask the client if she takes a daily calcium tablet
b. Extend the leg and dorsiflex the foot
c. Lower the leg off the side of the bed
d. Elevate the leg above the heart
b. Extend the leg and dorsiflex the foot
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client
is capable) (B) and putting the heel of the foot on the floor is the best means of relieving
leg cramps.
The nurse is caring for a woman with a previously diagnosed heart disease who
is in the second stage of labor. Which assessment findings are of greatest
concern?
a. edema, basilar rales, and an irregular pulse
b. Increased urinary output, and tachycardia
c. Shortness of breath, bradycardia, and hypertension
d. Regular heart rate, and hypertension
Edema, basilar rales, and an irregular pulse (A) indicate cardiac decompensation and
require immediate intervention.
2
