Maternity HESI Test Bank 2023 Complete Solution

Maternity HESI Test Bank 2023 Complete Solution. A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A.Breastfeed the infant, ensuring that both breasts are completely emptied. B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C.Breastfeed on the unaffected breast only until the mastitis subsides. D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. A.Breastfeed the infant, ensuring that both breasts are completely emptied. Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease antibiotic effects on the infant. A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet C.Move about every hour. Rationale: Pooling of blood in the lower extremities 2 / 69 Maternity HESI Test bank (combined red hesi and other sources) have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities? A.Wear support stockings. B.Reduce salt in the diet. C.Move about every hour. D.Avoid constrictive clothing. results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return. Option A would increase venous return from varicose veins in the lower extremities but would be of little help with swelling. Option B might be helpful with generalized edema but is not specific for edematous lower extremities. Option D does not address venous return, and there is no indication in the question that constrictive clothing is a problem. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A.Cephalhematoma, which is caused by forceps trauma B.Subarachnoid hematoma, which requires immediate drainage C.Molding, which is caused by pressure during labor D.Subdural hematoma, which can result in lifelong damage A.Cephalhematoma, which is caused by forceps trauma Rationale: Cephalhematoma, 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 skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could not be detected by physical assessment alone. Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? C.Allow the cord to air-dry as much as possible. 3 / 69 Maternity HESI Test bank (combined red hesi and other sources) A.Wash the cord frequently with mild soap and water. B.Cover the cord with a sterile dressing. C.Allow the cord to air-dry as much as possible. D.Apply baby lotion after the baby's daily bath Rationale:Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because they promote moisture and increase the potential for infection. A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B.Wash off the yellow exudate on the glans once every day to prevent infection. C.Place petroleum ointment around the glans with each diaper change and cleansing. D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs. C.Place petroleum ointment around the glans with each diaper change and cleansing. Rationale: With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider. A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulC.Tachycardia and a feeling of nervousness Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimu4 / 69 Maternity HESI Test bank (combined red hesi and other sources) fate? A.Drowsiness and paroxysmal bradycardia B.Depressed reflexes and increased respirations C.Tachycardia and a feeling of nervousness D.A flushed warm feeling and dry mouth lates 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. Option A is not a side effect. Options B and D are side effects of magnesium sulfate. A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness? A.Wear a cotton bra with nonbinding support. B.Increase nursing time gradually over several days. C.Ensure that the baby is positioned correctly for latching on. D.Manually express a small amount of milk before nursing. C.Ensure that the baby is positioned correctly for latching on. Rationale: The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent chafing, and nonbinding support aids in prevention of discomfort from the stretching of the Cooper ligament. Option B is important but is not necessary for all women. Option D helps soften an engorged breast and encourages correct infant latching on but is not the best answer. A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate? A."Weigh the baby daily, and if she is gaining weight, she is getting enough to eat." B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." Rationale: The urine will be dilute (straw-colored) and frequent (6 to 10 5 / 69 Maternity HESI Test bank (combined red hesi and other sources) B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." C."Offer the baby extra bottled milk after her feeding and see if she still seems hungry." D."If you're concerned, you might consider bottle feeding so that you can monitor intake." times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately, and the suggestion will likely make the mother anxious. Option C causes nipple confusion and diminishes the mother's milk production. Option D does not address the client's question. The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.) A.Pain in the lower back that radiates to abdomen B.Contractions decreased in frequency with ambulation C.Progressive cervical dilation and effacement D.Discomfort localized in the abdomen E.Regular and rhythmic painful contractions A.Pain in the lower back that radiates to abdomen C.Progressive cervical dilation and effacement E.Regular and rhythmic painful contractions Rationale: These are all signs of true labor. Options B and D are signs of false labor. Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." Rationale: Continuous breastfeeding on 6 / 69 Maternity HESI Test bank (combined red hesi and other sources) my period." B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." C."I can start smoking cigarettes while breastfeeding because it will not affect my breast milk." D."When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings. a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method. Option B is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk. Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings. A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best? A."This is not an unusually shaped head, especially for a first baby." B."It may look odd, but newborn babies are often born with heads like that." C."That is normal. The head will return to a round shape within 7 to 10 days." D."Your pelvis was too small, so the head had to adjust to the birth canal." C."That is normal. The head will return to a round shape within 7 to 10 days." Rationale: Option C reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although option A is correct, it implies that the client should not worry. Any implied or spoken "don't worry" is usually the wrong answer. Option B is condescending and dismissing; the mother is seeking reassurance and information. Option D is a negative statement and implies that molding is the mother's fault. Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately? C.Place the client in a lateral position. Rationale: The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the 7 / 69 Maternity HESI Test bank (combined red hesi and other sources) A.Notify the health care provider or anesthesiologist. B.Continue to assess the blood pressure every 5 minutes. C.Place the client in a lateral position. D.Turn off the continuous epidural. rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice. Option D may also be warranted, but such action is based on hospital protocol. The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? A.Avoid alcohol because it is excreted in breast milk. B.Eat a high-roughage diet to help prevent constipation. C.Increase caloric intake by approximately 500 cal/day. D.Increase fluid intake to at least 3 quarts each day. A.Avoid alcohol because it is excreted in breast milk. Rationale: Alcohol should be avoided while breastfeeding because it is excreted in breast milk and may cause a variety of problems, including slower growth and cognitive impairment for the infant. Options B, C, and D should also be included in diet teaching for a breastfeeding mother; however, because these do not involve safety of the infant, they do not have the same degree of importance as option A. A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A.Come to the clinic today for an ultraA.Come to the clinic today for an ultrasound. Rationale:Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdom8 / 69 Maternity HESI Test bank (combined red hesi and other sources) sound. B.Go immediately to the emergency department. C.Lie on your left side for about 1 hour and see if the bleeding stops. D.Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI). inal ultrasound. Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which is life threatening to the mother and fetus. If those symptoms were described, option B would be appropriate. Option C does not address the cause of the symptoms. The client is not describing symptoms of a UTI. A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement? A.Place a wedge under the client's left side. B.Determine cervical dilation and effacement. C.Administer 10 L of oxygen via facemask. D.Increase the rate of the oxytocin (Pitocin) infusion. B.Determine cervical dilation and effacement. Rationale: The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time. A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing C.Impaired bowel motility related to pain medication and immobility 9 / 69 Maternity HESI Test bank (combined red hesi and other sources) to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A.Altered nutrition, less than body requirements for lactation B.Alteration in comfort related to nausea and abdominal distention C.Impaired bowel motility related to pain medication and immobility D.Fatigue related to cesarean delivery and physical care demands of infant Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is not as important as impaired motility. The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A.January 14 to 15 B.January 22 to 23 C.January 29 to 30 D.February 6 to 7 C.January 29 to 30 Rationale: This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect. In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan?