HESI RN MATERNITY

HESI RN MATERNITY EXAM QUESTIONS AND ANSWERS Which finding for a client in labor at 41­weeks gestation requires additional assessment by the nurse? Cervix dilated 2 cm and 50% effaced. Score of 8 on the biophysical profile. Fetal heart rate of 116 beats per minute. One fetal movement noted in an hour. A client at 28­weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? Contraction stress test. Internal fetal monitoring. Abdominal ultrasound. Lecithin­sphingomyelin ratio. A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? Document the color of the lochia. Observe maternal vital signs. Assist the client to the bathroom. Notify the healthcare provider. A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next? Determine the firmness of the fundus. Give oxytocin (Pitocin) intravenously. Inform the healthcare provider of the bleeding. Assess the vital signs for indicators of shock. The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? Give 10 liters of oxygen via face mask. Prepare for an emergency cesarean section. Continue to monitor the fetal heart rate pattern. Obtain an oral maternal temperature. A client at 28­weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? Vaginal bleeding. Complaints of abdominal pain. Changes in fetal heart rate patterns. Alteration in maternal blood pressure. Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)? Woman whose blood group is AB Rh­positive. Newborn with rising serum bilirubin level. Newborn whose Coombs test is negative. Primigravida mother who is Rh­negative. The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion? The client needs to void. Amniotic membranes rupture. Uterine contractions occur every 8 to 10 minutes. The fetal heart rate is 180 bpm without variability A client in labor receives an epidural block. What intervention should the nurse implement first? Encourage oral fluids. Assess contractions. Monitor blood pressure. Obtain a radial pulse. A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. What action should the nurse implement next? Recheck the client's vital signs. Notify the healthcare provider. Insert an indwelling urinary catheter. Massage the fundus in 30 minutes. The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand? Plan for a possible cesarean birth. Arrange for home uterine monitoring. Make arrangements for care at home. Report uterine cramping or low backache. The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? Check the infant's arterial blood gases. Notify the pediatrician of the infant's vital signs. Assess the infant's blood glucose level. Encourage the infant to take the breast or sugar water. Rationale The nurse should first assess the infant's blood glucose level (C), because the infant is displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy demands. The infant's respiratory and heart rates are within normal limits, so (A) is not a priority. (B and D) would be implemented after information regarding the blood sugar level has been obtained. What action should the nurse implement when caring for a newborn receiving phototherapy? Reposition every 6 hours. Place an eyeshield over the eyes. Limit the intake of formula. Apply an oil-based lotion to the skin. Rationale Phototherapy converts unconjugated bilirubin, which is deposited in the skin, to a water-soluble form that is more easily excreted by the liver. Exposure to the light source can increase the risk for ocular damage, so an eyeshield (B) is placed while the infant is under the light source. To ensure all body surfaces are exposed to the lights, the newborn should be reposition every 2 to 4 hours, not every 6 hours (A). Phototherapy can increase insensible water loss, and to prevent dehydration, fluid intake should be encouraged, not restricted (C). Lotions (D) absorb heat and can potentially cause burns and should not be used on the skin while phototherapy is in progress. The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement? Notify the healthcare provider of fetal status. Give oxygen at 10 L per nasal cannula. Place the client in a side-lying position. Increase the flow rate of intravenous fluids. Rationale Variable decelerations are caused by compression of the umbilical cord and are evidenced by V shape appearance, characterized by a rapid descent and ascent to and from the depth of the deceleration. To alleviate the pressure on the umbilical cord, the nurse should reposition the client into a side-lying position (C). Once the client is repositioned and evaluated, then (A, B, and D) should be implemented. A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? Document the color of the lochia. Observe maternal vital signs. Assist the client to the bathroom. Notify the healthcare provider. Rationale Fundus displacement commonly occurs in the early hours of the postpartum period due to urinary retention, so assisting the client to the bathroom (C) to void should be implement next. (A and B) can be completed after the client's bladder is emptied. (D) should only be implemented if the fundus does not become firm or lochial bleeding continues after the bladder is emptied. A client at 35-weeks gestation visits the clinic for a prenatal check-up. Which complaint by the client warrants further assessment by the nurse? Periodic abdominal pain. Ankle edema in the afternoon. Backache with prolonged standing. Shortness of breath when climbing stairs. Rationale Abdominal pain (A) may indicate preterm labor or placental abnormalities, so specific information should be gathered about the intensity, location, and circumstances surrounding the pain. (B, C, and D) are expected findings at 35-weeks. A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider? Bruising. Oral intake. Hemoglobin. Bilirubin. Rationale Neonatal erythrolysis due to Rh incompatibility causes rapid release of unconjugated bilirubin (D), which results in serum levels (hyperbilirubinemia) that place the infant at risk for neurological damage (kernicterus). (A, B, and C) may influence the serum bilirubin level, but the most significant finding is the serial bilirubin levels that determines the need for early intervention. A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement first? Administer 10 L of oxygen via face mask. Give the healthcare provider a status report. Place the client in the knee-chest position. Wrap the cord with gauze soaked in saline. Rationale Until an emergency delivery is accomplished, the client should be placed in a knee-chest position (C) to relieve compression of the presenting part on the umbilical cord, which can compromise fetal oxygenation. (A, B, and C) are implemented after the client is positioned to relieve pressure on the umbilical cord. The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37-weeks gestation. What nursing action should be implemented first? Provide tactile stimulation. Administer flow by 100% oxygen. Asses the functionality of the monitoring device. Evaluate the newborn's color and respirations. Rationale Monitors are an effective method for continual appraisal of a neonate's respirations, but a visual assessment of the infant oxygenation and respiratory status (D) should be implemented first. If the infant is not breathing, then tactile stimulation (A) should be given for no longer than 10 to 15 seconds before initiating CPR. Oxygen should be administered or increased (B) after determining the neonate's respiratory status. If there is normal color and presence of respirations after assessment, then possible causes of a false alarm (C) should be investigated for mechanical malfunction of the device. While inspecting a newborn’s head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? Molding. Cephalohematoma. Caput succedaneum. Bulging fontanel. Rationale A cephalohematoma (B) should be documented because it is a collection of blood beneath the periosteum of the cranial bone causing scalp swelling that does not cross the suture line. Molding (A) is overlapping of cranial bones that occurs as the fetal head accommodates for the descent through the vaginal vault. Caput succedaneum (C) is differentiated from a cephalohematoma by generalized edematous swelling of the presenting part of the head. Fontanel tension should feel slightly concave and well defined against the edges of the cranial bones, whereas a bulging anterior fontanel (D) is tense and distends from an increased intracranial pressure, such as seen in congenital hydrocephalus. When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? Quiet the infant before counting the heart rate. Listen at the apex of the heart. Count the heart rate for at least one full minute. Palpate the umbilical cord. Rationale It is most important for the nurse to count the heart rate for at least one full minute (C) so that irregularities or murmurs can be detected. (A) is not necessary for the heart rate to be correctly auscultated. The heart rate can be heard clearly over any point of an infant's chest, not just (B). Immediately after delivery, (D) will allow the nurse to assess the rate, but (B) is the most accurate method of obtaining a newborn's heart rate. At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villus sampling (CVS) procedure. What assessment finding requires immediate intervention? Uterine cramping. Abdominal tenderness. Systolic blood pressure 100 mmHg. Intermittent nausea. Rationale The client should be monitored for 1 to 2 hours following the procedure for the occurrence of uterine cramping (A) so that immediate intervention to decrease the risk of miscarriage can be initiated. This procedure (removal of a small piece of tissue from the fetal portion of the placenta) may cause initiation of labor. (B) may occur at the puncture site if the procedure was done transabdominally. (C and D) are normal findings during in the first trimester. A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first? Prepare the client for imminent birth. Assess the fetal heart rate and pattern. Document the characteristics of the fluid. Notify the client's primary healthcare provider. Rationale The fetal heart rate and pattern should be assessed (B) to determine compromise of fetal well-being caused by compression or prolapse of the umbilical cord. The intensity and frequency of the uterine contractions often trigger spontaneous rupture of the membranes (SROM), which does not indicate that birth is imminent (A). The healthcare provider should be notified of the client and fetal well-being after evaluation of SROM. Although the characteristics of the amniotic fluid should be documented (C), assessment of fetal response to the SROM is the priority. A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action? Assess newborn reflexes for signs of neurological impairment. Leave the infant in the room with the mother to foster attachment. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. Perform a gestational age assessment to determine if the infant is large- for-gestational-age A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client? During second trimester beer can be consumed without harm to the fetus. Wine can be consumed several times a week after the first trimester. Only one drink with the evening meal is not harmful to the fetus. Abstinence is strongly recommended throughout the pregnancy. Rationale A safe level of alcohol consumption during pregnancy has not yet been established, so although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised (D). Beer (A), wine (B) or any alcoholic drink (C) consumption is not recommended during the pregnancy. Which finding for a client in labor at 41-weeks gestation requires additional assessment by the nurse? Cervix dilated 2 cm and 50% effaced. Score of 8 on the biophysical profile. Fetal heart rate of 116 beats per minute. One fetal movement noted in an hour. Rationale A count of less than three fetal movements within 1 hour (D) warrants further evaluation using nonstress or contraction stress testing, biophysical profile, or a combination of these tests. A cervical exam of 2 cm and 50% effacement (A) and a fetal heart rate of 116 (C) are normal findings. A score of 8 on a biophysical profile (B) indicates a normal infant with low risk for chronic asphyxia. A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, what action should the nurse implement? Escort the client to the bathroom. Offer the client a bed pan. Perform a nitrazine test. Clean the perineal area. Rationale The normal characteristic of amniotic fluid is pale, straw-colored fluid, which may contain white flecks of vernix, with an alkaline pH, so (C) should be done to confirm the pH of the fluid. (A or B) may be indicated if the fluid is urine. (D) should be done after determining the type of fluid expelled. A client at 28-weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client? It is not necessary to keep such a close watch on weight gain. Try to exercise more because too much weight has been gained. Increase the calories in your diet to gain more weight per week. The weight gain is acceptable for the number of weeks pregnant. Rationale The normal pattern of weight gain is 2 to 4 pounds in the first trimester (by 13-weeks) and 1 pound per week after that. At 28- weeks gestation, a weight gain between 17 and 20 pounds is acceptable (D). (A, B and C) do not provide accurate information. A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which designation is the most accurate summary of this client's obstetrical history? 3-1-1-1-3. 4-1-2-0-3. 3-0-3-0-3. 4-3-1-0-2. Rationale The client with 3 previous gravid experiences and this current pregnancy totals 4 gravid experiences, and 1 term delivery (37- weeks or greater), 2 preterm deliveries (20 to 37 weeks, whether viable or not viable), no spontaneous abortions and 3 living children. (B) best designates this client's obstetrical history. (A, C, and D) are inaccurate for this client's history using the TPAL system. While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding? Molding. Hemangioma. Cephalohematoma. Caput succedaneum. Rationale Caput succedaneum (D) is characterized by swelling of the soft tissues of the scalp that extends across suture lines. Molding (A) of the head results from adjustment of the infant’s skull structure, which allows for the passage of the infant’s head through the birth canal and is a common occurence in vaginal deliveries. Hemangioma (B) is a collection of blood vessels close to the skin. Cephalohematoma (C) is an edematous area caused by extravasation of blood between the skull bone and periosteum and does not cross the suture lines, which differentiates it from caput succedaneum. While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change? Fetal well being with labor progression. Signs of uteroplacental insufficiency. Episodes of fetal head compression. Occurrences of cord compression. Rationale Fetal heart rate accelerations that last 15 to 20 seconds are a sign of fetal well-being, so continuous external fetal monitoring should be continued (A). Uteroplacental insufficiency (B) causes late decelerations. Compression of the fetal head (C) results in early decelerations. Compression of the umbilical cord (D) is evidenced by variable decelerations. A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first? Ventilate with an Ambu bag. Perform nasal and airway suctioning. Administer supplemental oxygen. Gently rub the infant's feet or back. Rationale Gentle stimulation of the infant's feet and back (D) can cause an infant to resume spontaneous respirations. If the infant does not respond to manual stimulation, resuscitative measures should be implemented using Ambu bag ventilation (A), suctioning (B), and the administration of oxygen (C).