OB HESI Exam Test Bank Latest Update 2023/2024- 100% Verified Q&A

OB HESI Exam Test Bank Latest Update 2023/2024- 100% Verified Q&A OB HESI Exam Test Bank 1. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV oxytocin is infused. When notifying the healthcare provider of the client’s condition, which information is most important to provide? Maternal blood pressure a. 2. A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32 weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention? Ask the client if she has experienced any recent changes in a. vaginal discharge 3. A client who is HIV positive is receiving zidovudine during labor. Which information should the nurse provide the client? This treatment helps prevent transmission of the virus to the a. fetus 4. The nurse is preparing to draw blood from a newborn to obtain hemoglobin and hematocrit levels. What is the best method to obtain this blood sample? Use a lancet to puncture the outer lateral aspect of the heel. a. Stop the magnesium sulfate infusion immediately 5. In assessing a client diagnosed with preeclampsia who is receiving magnesium sulfate, the nurse determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/min; urinary output is 90 mL in 4 hours; magnesium sulfate levels is 9 mEq/L. Based on these findings, what intervention should the nurse implement? a. 6. The nurse is assessing a client at 29 weeks gestation. Which assessment method would provide the most accurate determination of fetal position? a. Ultrasound 7. A client in labor states “ i think my water just broke” the nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? Place the client in trendelenburg a. 8. A client who is 14 days postpartum arrives to the clinic for a followup examination. The nurse is unable to palpate the uterine fundus. Which action should the nurse take Document the normal finding a. Low back pain with pelvic cramping 9. Following an amniocentesis a client verbalizes severall complaints. What reported finding indicates the nurse that the client is experiencing a complication form the amniocentesis a. 10.A client who is positive for gonorrhea vaginally delivered a newborn. Which medicdation should the nurse administer? Erythromycin ointment a. 11.The current vital signs for a promipara who delivered vaginally during the previous shift are: temp 100.4, HR 58 beats/min, respiratory rate 16 breaths/min, and BP 130/74 mmHg. What action should the nurse implement? Document the vital signs in the record a. 12.Which content should the nurse plan to include in a nutrition class for pregnant adolescents? Take folic acid supplements daily a. Increase food intake by 300 to 400 b. calories per day c. Take iron and calcium supplements daily 13.After placing a 36 week gestation newborn in an isolette and drying teh infant with several blankets, what should the nurse implement next? Place erythromycin ophthalmic ointment in both eyes a. 14.While on the delivery table a primipare tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement? Evaluate the infants sucking reflex then give the infant to the a. mother 15.The nurse is assessing a pregnant client who reports she smokes one pack of cigarettes per day. The client believes she is 6 months pregnant, but is unsure of the date of her LMP. which method of assessment provides the best estimate if gestational age? a. Ultrasonography 16.A primigravida client is in the 4th stage of labor after the delivery of a newborn male infant. Which information should the nurse provide? Techniques to breastfeed a. 17.Prior to performing a postpartum assessment, the client tells the nurse, “i have pain in my stitches”. The nurse knows that the client had a mid-line episiotomy. Which action should the nurse take first? Visualize the perineum and check the episiotomy a. 18.….radioactive iodine. She confides in the nurse that she may be pregnant and plans to have an abortion right away if the pregnancy is confirmed. She asks the nurse to keep the information confidential. Which action should the nurse take Explain to the client that the procedure will need to be canceled a. until confirmation is obtained that the client is not pregnant 19.A woman is brought to the labor and delivery unti after delivering a term infant and the placenta in the hospital parking lot 10 mins ago. Which action should the nurse perform first Massage the fundus and give an oxytocic agent a. 20.A breastfeeding woman who delivered her infant two weeks ago develops mastitis in her left breast. A cephalosporin antibiotic is prescribes from the pediatritian. Which instruction regarding breastfeeding should the nurse provide? Initiate feeding on the unaffected breast first a. 21.A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol. How should the nurse respond You may be at higher risk for having a spontaneous miscarriage a. 22.In preparing a gravid client for a triple screen analysis, which action should the nurse take? Prepare to draw blood for analysis a. 23.32 week gestation presents wil extreme abdominal tenderness and a small amount of bright red vaginal bleeding. BP is 95/65, RR is 24 and her HR is 116. She is dizzy, with cold clammy skin. Which prescription has highest priority Lactated ringers at 200 ml/hr using an 18 gauge needle a. 24.The nurse is caring for a client following an emergency c-section under general anesthesia. Which assessment finding occurring in the first 8 hours after delivery is most critical and requires immediate intervention Uterine atony a. 25.40 week gestation receives atropine and an adjunct to inhalation anaesthesia for scheduled c-section. Which finding should the nurse identify as a therapeutic response to the injection? Increase pulse and reduced oral secretions a. 26.Client who is 12 weeks pregnant has type 1 DM. instructuion should nurse provide related to insulin doages Increases from 18 weeks to approximately 36 weeks a. 27.Oxytocin induction started for a gravid client 8 hours ago. When assessing FHR nurse notes a U shaped pattern occurring with the peak of the contraction. Intervention to implement first Change the position of the client a. 28.One week old full term infant is readmitted for hyperbilirubinemia. Supplies needed for treatment plan’ Eye shield patches and an artificial light source for phototherapy a.  29.A client whose labor is being augmented with an oxytocin infusion requests and epidural for pain control. Findings of last vagianl exam performed 1 hour ago, were 3 cm cervical dilation and 60% effacement and a -2 station. Which action should the nurse implement 1st Determine current cervical dilation a. 30.Postpartum client is rh neg refuses rhogam after delivery of infant who is rh positive. Which information should the nurse provide this client Rh positive factor from the fetus threatens her blood cells a. 31.Client has history of substance abuse is attempting to breastfeed at 24 hours postpartum. Nurse observes infant is irritable with high pitched cry, exhibits nasal stuffiness and is having trouble latching. Which toxicology screening reslut would indicate these infant behaviors a. opioids 32.Multiparous woman who is 2 months postpartum reports not feeling like herself, not wanting to care for her children, and desiring to sleep all the time. How should the nurse respond Join a local support group a. 33.Primigravida who is 33 weeks presents to labor and delivery with complaints of a headache. Initial assessment findings: BP 144/96, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next. Temp, pulse and RR a. 34.Nurse reviewing the genetics test report for a pregnant client with a history of several spontaneous abortion. The results show client has a homozygous x-linked dominant inheritance disorder. How should nurse explain There is a 50% chance of passing this gene on to all children a. Perform transillumination of the scortal sac to visualize a red 35.Scrotal sac is large, swollen, smooth and taut. What assessment technique should be performed to determine if infant has hydrocele a. glow of fluid around the testes 36.Routine prenatal visit, client complains that urinary frequency has increased during the day as well as at night. Nurse determines the client is having irregular uterine contractions. Action nurse should implement Obtain midstream urine speciemen for culture a. a. Your baby was given an injection of 37.New mother asks why infant has needle mark on his leg. Best response vitamin K to prevent bleeding 38.Nurse should monitor closley which newborn for increased risk for developing neonatal sepsis Reported prolonges rupture of membranes a. 39.Nurse preparing to admin methylorgonovine to postpartum client. What findig should nurse withhold the drug a. BP 149/90 40.Receiving oxytocin for labor augmentation, asks for pain meds, was medicated 30 mins ago. Action nurse should implement Instruct client to use deep breathing during a contraction a. 41.31 weeks with fundal height of 25 cm is scheduled for a series fo ultrasounds every 2 weeks. Which explanation should nurse provide for the ultrasounds Evaluation of fetal growth a. 42.Ruptured membranes 12 hours prior to coming to hospital. Oxytocin infusion is begun and 8 hours later the clients are irregular and mild. Nurse plans to monitor which sign more frequently than for the average laboring client Maternal temp a.  43.AA client is at 24 weeks. Which prenatal lab assessment prescribed at 26 weeks should the nurse One hour glucose screen a. 44.Demonstrating cyanosis of the hands and feet. What action should nurse take a. Continue to monitor 45. her fundal height is at 29 cm. Based on findings which action should be taken a. Document the finding in the medical record 46.Postpartum client has a continuous dribbling of bright red blood from her vagina. Her uterus is firm and her vitals are within normal limits. May indicate? Laceration on the cervix a. 47.35 week inant delivered by c-section 2 hours ago. Nurse observes inants RR rate is 72 with nasal flaring, grunting and retractions. Transient tachypnea of the newborn Nurse should recognize these findings indicate which complication a. 48. HR is 100 Provide positive pressure ventilation a. a. Active herpes lesions on the 49.Client in active labor. When should you notify surgery team to prepare for csection perineum 50.Father of 3 day old infant is breat feeding calls postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cries for no reason. What information is most important for nurse to provide this father Contact the clinic if the behaviors continue or more than 2 a. weeks or becomes worse. 51.A woman in her third trimester has been in active labor for past 8 hours and has dilated 3cm. The nurses assessment findings and electronic fetal monitoring are consistent with  Intensity, interval, and length of contractions hypertonic dystocia and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor? a. 52.A new mother who is breastfeeding her 4 week old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement Inform her that a decrease need for insulin occurs while a. breastfeeding 53.Newborns head circumference 12 inches, chest 13 inches. No molding and infant was breech presentation delivered by c-section. What action should the nurse take based on this data Record the findings on the chart. They are within normal limits a. 54.Nurse notes on fetal monitor that a laboring client has variable deceleration. Which action should the nurse implement first Change clients position a. Ecchymotic knees 55.Ambulatory client at 39 weeks gestation presents to emergency room with an obvious injury to her arm that occurred as the result of a fall. Which concurrent symptom is a priority for the nurse a. 56.Newborn assessment reveals spina bifida. Maternal factor having greatest impact on development of this complication Folic acid deficiency a. 57.Nurse places newborn supine under a radiant warmer, an external heat source. What should nurse implement to ensure safe thermoregulation Place temp probe on abdomen in line with the radiant heat a. source 58.At 6 weeks gestation the rubella titer of a client indicates she is not immune. Whenis the best time to administer a rubella vaccine Early postpartum within 72 hours of delivery a. 59.Woman trying to get pregnant tells nurse she was disappointed several months ago when she was informed that her positive pregnancy test was a false method provides greatest degree of accuracy Visualization of implantation by vaginal ultrasound a. 60.Nurse is planning discharge teaching to 4 mothers. Which postpartum client is at highest risk for a psychological difficulty during the postpartum period Primiparous woman who has recently immigrated to the U.S with a. her spouse 61.35 weeks gestation complains of pain whenever the baby moves. On assessment the nurse notes the clients temp to be 101.2 with severe abdominal or uterine tenderness on palpation. Nurse knows that these findings are indicative of which condition. a. Chorioamnionitis 62.UAP reports to charge nurse that a client who delivered a 7 pound infant 12 hours aho is reporting severe headache. Clients BP is 110/70, RR is 18, HR is 74 and temp is 98.6. Clients fundus is firm and one finger breadth above the umbillicus. Which action should the charge nurse implement first. Notify healthcare provider of the assessment findings a. 63.Nurse is preparing to administer phytonadione to newborn. Which statement made by the parents indicates understanding why the nurse is administering the med Prevent hemorrhagic disorders a. 64.16 year old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convlusing. Which intervention should the nurse plan to include in the clients nursing care plan Keep and airway at the bedside a. 65.Pregnant client presents to antepartal clinic complaining of brownish vaginal bleeding. Nurse notes she has a greatly enlarges uterus and is complaining of severe nausea. Client reports that her period was about 2 and a half months ago. Vitals are temp 98.7, pulse 70, RR 18 and BP 190/110. Based on these findings which lab value should the nurse review hCG values a. 66.A woman who is 38 weeks gestation is receiving mag sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse a. Absent patellar reflexes Begin oxytocin 4 hours after misoprostol is given 67.Primigravida client with gestational hypertension and bishop score of 3 is scheduled for induction of labor. Nurse administers misoprosptol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take a. 68.Nurse is caring for a client whose fetus died in utero at 32 weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. Which action is important for the nurse to take Encourage the mother to hold and spend time with her baby a. 69.Following a minor motor vehicle collision a client at 36 weeks is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her BP is Tilt the backboard sideways to displace the uterus laterally 80/59, HR is 130. Which action should nurse implement first a. 70.A new mother asks the nurse about an area of swelling on her babys head near the posterior fontanel that lies across the suture line. How should nurse respond That is called caput succedaneum. It will absorb and cause no a. problem 71.Nurse is caring for a client following an emergency c-section under general anesthesia. Which assessment finding occurring in the first 8 hours after delivery is most crucial and requires immediate interventions Uterine atony a. Measure vital signs 72.Nurse is caring for a client who is 10 weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take a. 73.Nurse is conducting a home health visit of a client who delivered 3 weeks ago and is formula feeding the infant. Which observations should the nurse find most concerning Clients eyes are red from crying and the infant is fussing in the a. crib? 74.A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the record and observes there has beena rapid weight gain in 6 weeks. Which action should the nurse implement next Obtain a blood pressure OR listen to fetal heart rate a. Position a radiant warmer over the crib 75.Nurses assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first a. 76.A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. the nurse applies the external fetal heart monitor and determines she is not in labor. What makes the nurse realize she is not in labor? Contractions stop when the client is walking a. 77.A primipara client at 42 weeks gestation is admitted for induction. within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occuring every 1 minute with a 75 second duration. when nurse stops the oxytocin and starts oxygen. after 30 minutes of uterine rest, the contractions are occuring every 5 minutes with 20 second duration. which intervention should the nurse implement? Restart the oxytocin per oxytocin protocol a. nurse is caring for a 35 week gestation infant delivered by cesarean section 2 hours ago. the nurse observes the infants respiratory rate is 72 breaths minute with nasal flaring, grunting, and retractions. the nurse should recognize these finding indicate which complication? Transient tachypnea of the newborn a. 79.The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority? a. Hypoglycemia 80.The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist arrival on the unit, which action should the nurse perform? Place procedure equipment at bedside a. 81.At 0600 while admitting a woman for a scheduled repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? Inform the anesthesia care provider a. 82.A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour labor. What is the priority nursing action for this client? a. Massage the fundus every 4 hours 83.A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client? Use alternative form of birth control until new diaphragm can be a. obtained 84.A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes the nurse observes several shallow small vesicles on her pubis labia and perineum. the nurse should recognize the clients is prohibiting symptoms of which condition? Herpes simplex virus a.