NURSING
Maternity HESI
1
1. 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?
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.
2. 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?
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".
3. When do the anterior and posterior fontanels close?
anterior fontanel closes at 12 to 18 months and the posterior by the end of
the second month.
4. 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?
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.
5. The nurse should encourage the laboring client to begin
pushing when... the cervix is completely dilated.
1
, NURSING
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
2
, NURSING
delivery. Many primigravida’s begin active labor 100% effaced and then proceed to
dilate.
6. 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?
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.
7. 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...
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.
8. When does the head return to its normal shape?
7-10 days
9. What did Nurse theorist Reva Rubin describe?
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.
10. 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?
Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub
diaphragmatic collection of peritoneal dye/gas.
11. Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?"
3
, NURSING
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.
4
Maternity HESI
1
1. 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?
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.
2. 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?
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".
3. When do the anterior and posterior fontanels close?
anterior fontanel closes at 12 to 18 months and the posterior by the end of
the second month.
4. 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?
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.
5. The nurse should encourage the laboring client to begin
pushing when... the cervix is completely dilated.
1
, NURSING
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
2
, NURSING
delivery. Many primigravida’s begin active labor 100% effaced and then proceed to
dilate.
6. 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?
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.
7. 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...
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.
8. When does the head return to its normal shape?
7-10 days
9. What did Nurse theorist Reva Rubin describe?
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.
10. 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?
Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub
diaphragmatic collection of peritoneal dye/gas.
11. Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?"
3
, NURSING
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.
4
