Maternity HESI

1. A primipara has delivered a stillborn fetus at 30-weeks gestation. To assist the parents with the grieving process, which intervention is most important for the nurse to implement? A. Provide an opportunity for the parents to hold their infant in privacy. B. Assist the couple in completing a request for autopsy C. Encourage the couple to seek family counseling within the next few weeks D. Explain the possible causes of the fetal demise Answer: A . Step-by-Step explanation The correct answer is A. Provide time for parents to hold their infant in privacy. By doing so the parents will be convinced that the infant is actually gone and will help them in their grieving process and thus can heal. 2. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula? A. Body temperature B. Level of pain C. Time of first void D. Number of vessels in the cord Answer: A . Step-by-Step explanation As there is already deformity in the baby so the nusre need to check other body systems. Respiratory stress increases body temperature, it should be the priority assessment. 3. What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation? A. Maternal blood pressure B. Level of pain sensation C. Station of presenting part D. Variability of fetal heart rate Answer: A . Step-by-Step explanation The answer is A - Maternal blood pressure. Epidural anesthesia is used as a pain reliever during child labor. This will paralyze the area where the anesthesia is conducted, and it will create a senseless feeling from the mother's belly to the upper legs. The nurse should check the blood pressure of the mother because one of the side effects of taking epidural anesthesia is the decrease in blood pressure. Because of that, the heart rate of the baby may be slow. Source (for further reading): Epidurals. (n.d.). American Society of Anesthesiologists. Retrieved April 15, 2021, from management/techniques/epidural/ 4. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is most important for the nurse to implement? A. Graph the daily weight for the past week B. Decreased IV flow rate C. Assess bilateral lung sounds D. Restrict intake oral fluids Answer: C . Step-by-Step explanation A nurse does the assessment of the bilateral lung sounds in order to distinguish the normal respiratory sounds from those that are not abnormal. The nurse also wanted to know the adequacy of respiration and make identifications on the changes in the function of the respiratory. Assessment of the bilateral lung sounds helps for the diagnosis and management of the pathological conditions that help the nurse in evaluating therapeutic interventions. Reference Nimdet, K., & Techakehakij, W. (2017). Congestive heart failure in children with pneumonia and respiratory failure. Pediatrics International, 59(3), 258-264. 5. A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, “Why is my baby sister eating my mommy’s breast?” How should the nurse respond? (Select all that apply) A. Explain that newborns get milk from their mothers in this way B. Reassure the older brother that it does not hurt his mother C. Remind him that his mother breastfed him too D. Suggest that the baby can also drink from a bottle E. Clarify that breastfeeding is his mother’s choice Answer: A . Step-by-Step explanation Human milk is an excellent source of nutrition for newborns. It contains age- appropriate nutrients, as well as immunological and antibacterial compounds. Colostrum, the fluid secreted immediately after a baby's birth, provides a high level of immune defense, particularly secretory Immunoglobin A (IgA), IgM, and IgG. Milk also provides biological signals that encourage cellular growth and differentiation. It also includes a number of antimicrobial substances which helps protect against infection. Breastfeeding has long-term benefits for both the mother and the baby. For example, women who breast feed have a lower risk of breast and reproductive cancer, and their children have increased adult intelligence independent of a wide range of possible confounding factors. Breastfeeding is linked to a reduction in postpartum weight gain. Furthermore, breast-fed babies have a slightly lower risk of sudden infant death syndrome. 6. The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used? A. Place the infant in side-lying position to facilitate the exam B. Hold the penis and retract the foreskin gently. C. Cleanse the penis with an antiseptic-soaked pad D. Place the infant in a warm room and use a calm approach Answer: D . Step-by-Step explanation Cryptorchidism is an abnormality during sexual development in males. This is the condition in which the testes don't descend from the abdominal part to the scrotum of the body. This is examined physically by the nurse by placing the infant in a warm and relaxed environment or room and a calm approach is used. The frog leg or catcher position will be useful in examining the abnormality. 7. Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child’s plan of care? A. Monitor serum glucose for adjustment in infusion rate of Regular insulin (Novolin R) B. Determine the child’s compliance schedule for subcutaneous NPH insulin (Humulin N) C. Demonstrate to parents how to program an insulin pen for daily glucose regulation D. Consult with healthcare provider about use of insulin detemir (Levemir Flex Pen) Answer: A . Step-by-Step explanation The answer is letter A. because it is the correct answer among the other choices. It is very important that the nurse should monitor the serum glucose of the child. The other choices are wrong answers.