Exam (elaborations) OB HESI EXAM (REVISED 2023/2024)

OB HESI EXAM (REVISED 2023/2024) OB HESI EXAM The nurse is caring for a newborn infant who was recently diagnosed with congenital heart defect. Which assessment finding warrants immediate intervention? A. Sweating during feeding B. Weak peripheral pulses C. Bluish tinge to the tongue D. Increased RR A client at 33 weeks gestation is admitted with a moderated amount of vaginal bleeding and no contractions are noted on the external monitor. What intervention should the nurse implement? A. Weigh perineal pad B. Weigh daily C. Measure I & O D. Ambulate 15 minutes QID A new mother, who is a lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge? A. Avoid using lanolin-based nipple cream or ointment B. Continue prenatal vitamins with b12 while breastfeeding C. Offer iron-fortified supplemental formula daily D. Weight the baby weekly to evaluate the newborn’s growth A primigravida at 36-weeks gestation, who is RH negative, experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the HCP? A. FHR of 162 bpm B. Trace of protein in the urine C. Positive fetal hemoglobin testing D. Mild contraction every 10 minutes The nurse is caring for a postpartal client who is exhibiting symptoms of spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist’s arrival to the unit, which action should the nurse perform? A. Place procedure equipment at bedside B. Apply and abdominal binder C. Cleanse the spinal injection site D. Insert an indwelling foley catheter The nurse is counseling a client who is 6-weeks gestation and experiencing morning sickness, but does not want to take any drugs for this discomfort. Which herbal supplement is likely to help this client with the nausea she is experiencing? A. Ginki B. Chamomile C. Peppermint D. Ginger The nurse is assessing a postpartum client who delivered a 10 lb infant vaginally 2 hours ago. The client’s fundus is 2 fingerbreadths above the umbilicus, deviated to the right side, and boggy. After the client voids 250 ml of urine using a bedpan, what action should the nurse implement? A. Re-evaluate the client in 15 minutes B. Assist the client to the bathroom to void C. Palpate the suprapubic region for distention D. Encourage the client to breastfeed At 0600 While admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? A. Ensure preoperative lab results are available B. Start prescribed IV with Lactates Ringers C. Inform the anesthesia care provider (quizlet) D. Contact the clients obstetrician Quizlet rationale: Surgical preoperative instructions include NPO after midnight the day of surgery to decrease the risk of aspiration should vomiting occur during anesthesia. While it is possible the C-section will be done on schedule or rescheduled for later in the day, the anesthesia provider should be notified first (C) to make that decision. The nurse should then implement (A and D). Based on the anesthesia provider's decision, the nurse may then proceed with (B). A client who is in active labor is receiving magnesium sulfate and begins to experience slurred speech and decreased reflexes. Which action should the nurse implement first? A. Obtain a serum magnesium level B. Measure the client’s hourly urinary output C. Provide an emesis basin for vomiting D. Turn off the magnesium sulfate infusion Calculated by Naegale’s rule, a primp client is at 28-week gestation. She is moderately obese and carrying twins and the nurse measures her fundal height at 27 cm. During previous visit 3 weeks ago, the fundal height measured at 28 cm. Based on these findings, what should the nurse conclude? A. Fundal height measurement may indicate intrauterine growth retardation B. The healthcare provider needs to be notified immediately since this fundal height measurement is greater than expected C. Confirm the fundal height measurement with another nurse D. Recognize this as a reasonable fundal height measurement for this client Following the vaginal delivery of a larger-for-gestational-age infant, a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client’s medical record describes Jehovah’s Witness noted as her religion. What action should the nurse take? A. Inform the client of the critical need for a blood transfusion (quizlet) B. Obtain consent from the family to infuse packed red blood cells C. Clarify the client’s wishes about receiving blood products D. Prepare to infuse multiple units of fresh frozen plasma The nurse is assessing a 35-week primp with a breech presentation who is experiencing moderate uterine contractions every 3 to 5 minutes. During the examination the client tell the nurse, “I think my water just broke.” Inspection of the perineal area reveals the umbilical cord protruding from the vagina. After activating the call bell system for assistance, what intervention should the nurse implement? A. Administer oxygen at 10 liters via face mask B. Don gloves and push the cord back into the vagina C. Wrap the umbilical cord with sterile gauze D. Position the client into the knee-chest position The nurse is discussing involution with a postpartum client. Which statement best indicates that the client understands the effect of breastfeeding on the resumption of menstrual cycle? A. My period will most likely return in 6 to 8 months B. I should expect my period to return in 6 to 8 weeks C. My period started as soon as the baby was born D. While I am breastfeeding, my period may be delayed A diabetic client delivers a full-term large-for-gestational-age infant who is jittery. What action should the nurse take first? A. Obtain a blood glucose level B. Administer oxygen C. Feed the infant glucose water D. Decrease environmental stimuli A 30-year-old primp delivers a 9 lb infant vaginally after a 30-hour labor. What is the priority nursing action for this client? A. Observe for signs of uterine hemorrhage B. Encourage direct contact with the infant C. Assess the blood pressure for hypertension D. Gently massage fundus every 4 hours A term multip, who is receiving oxytocin for labor augmentation, is requesting pain medication. Review of the client’s record indicates that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the client’s cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement? A. Medicate the client with an additional 1 mg of Stadol IV push B. Instruct the client to use deep breathing during a contraction C. Discontinue the Pitocin infusion D. Notify the HCP A multiparous client at 38-weeks gestation is admitted to labor and delivery with a complaint of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears a baby crying. What action should the nurse take first? A. Inspect the client’s perineum B. Turn on the infant warmer C. Notify the hcp D. Push the call light for help A client who is receiving oxytocin to augment early labor begins to experience hypersystolic or tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement? A. Reposition the fetal monitor transducers B. Alert the charge nurse to the patient’s condition C. Turn off the Pitocin infusion D. Decrease the rate of the Pitocin infusion The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement? A. Determine reactivity of neonatal reflexes B. Perform gestational age assessment C. Weigh and measure the newborn D. Obtain a drug screen for cocaine A newborn infant is receiving positive pressure ventilation after delivery. Based on which assessment finding should the nurse initiate chest compression? A. Apgar score 7 B. Heart rate 54 C. Limp muscle tone D. Central cyanosis Vaginal prostaglandin gel is used to induce labor for a woman who is at 42-weeks gestation. Thirst minutes after insertion of the gel, the client complains of vaginal warmth, and is experiencing 90 second contractions with fetal heart rate decelerations. What action should the nurse implement first? A. Notify the HCP B. Assess the maternal vital signs C. Turn to a side-lying position D. Increase the IV infusion rate A woman who delivered a normal newborn 24 hours ago complains, “I seem to be urinating every hour or so. Is that OK?” Which action should the nurse implement? A. Catheterize the client for residual urine volume B. Measure the next voiding, the palpate the client’s bladder C. Evaluate for normal involution, then massage the fundus D. Obtain a specimen for urine culture and sensitivity A client whose labor is being augmented with oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and -2 station. What action should the nurse implement first? A. Give a bolus of intravenous fluids B. Request placement of the epidural C. Determine current cervical dilation D. Decrease the oxytocin infusion rate One hour after delivery, the nurse is unable to palpate the uterine fundus of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next? A. Document number of pad changes in the last hour. B. Increase the rate of oxytocin infusion C. Palpate the suprapubic area for bladder distention D. Provide bedpan to void if unable to ambulate A client at 20-weeks gestation comes to the antepartal clinic complaining of vaginal warts (human papillomavirus). What information should the nurse provide this client? A. Treatment options, while limited due to the pregnancy, are available B. The client should be treated with penicillin g C. This client should be treated with acyclovir (zovirax) D. Termination of the pregnancy should considered. A multip client in labor is receiving oxytocin 4 mu/minute to help promote an effective contraction pattern. The available solution is Lactated Ringer’s 1,000 ml with Pitocin 20 units. The nurse should program the infusion pump to deliver how many ml/hour? 4 mu/ 1 min 1 u/1000 mu 1000ml/20 u 60 min/ 1 hr 240,000/20,000 12 ml/hr The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond? A. Explain the newborn’s normal stepping reflex B. Acknowledge the parents’ observation C. Encourage the parents to report this to the HCP D. Schedule the newborn for further neurological testing The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochia flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first? A. Heart rate and blood pressure B. Abdominal contour and bowel sounds C. Urinary output and IV fluid intake D. Hemoglobin and hematocrit The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of 8 pounds at 36-weeks gestation. The amniocentesis is being performed to obtain which information? A. Chromosomal abnormalities B. Fetal lung maturity C. Presence of a neural tube defect D. Gender of the fetus When performing a head-to toe assessment of a 1-day-old newborn, the nurse observes yellow tint to the skin on the forehead, sternum and abdomen. What action should the nurse take? A. Measure bilirubin levels using transcutaneous bilirubinometry B. Review maternal medical records for blood type and Rh factor C. Prepare the newborn for phototherapy D. Evaluate cord blood coomb’s test result A new mother asks the nurse about an area of swelling on her baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond? A. That is called caput succedaneum. It will absorb and cause no problems B. That is called a cephalhematoma. It will cause no problems C. That is called a cephalhematoma. It can cause jaundice as it is absorbed. D. That is called caput succedaneum. It will have to be drained. A 39-week-gestational multip is admitted to labor and delivery with spontaneous rupture of membranes and contractions every 2 to 3 minutes. A vaginal exam indicates the cervix is dilated 6 cm, 90% effaced, and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate has ranged between 170-180 bpm. What action should the nurse implement? A. Obtain a blood specimen for hemoglobin B. Take an oral maternal temperature C. Straight catheterize the client D. Send amniotic fluid for analysis An obviously pregnant woman walk into the hospital’s emergency department entrance, shouting, “Help me! My baby is coming! I’m so afraid!” The nurse determines that delivery is indeed imminent. What action is most important for the nurse to take? A. Determine the gestation age of the fetus (course hero) B. Assess the amount and color of the amniotic fluid (quizlet) C. Obtain peripheral IV access and begin administration of IV fluids D. Provide clear, concise, instructions in a calm, deliberate manner During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage? A. Palpate suprapubic area for fetal head position B. Insert straight urinary catheter to drain bladder C. Test fluid with nitrazine strip D. Scan the bladder for urinary retention A client who is 3-weeks postpartum tells the nurse, “I am so tired all of the time. I didn’t know having a baby would be so hard.” What response should the nurse provide? A. It is common to feel exhausted for the first 3 months. Try to sleep when the baby sleeps B. It is normal to feel tired for the first couple of weeks. Be patient with yourself and rest more. C. You should not be doing any housework. Are any of your family members helping you? D. Adjusting to a new baby can be difficult. Tell me more about any help you are receiving. The home health nurse visits a client who delivered a full term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curdlike patches on the newborn’s oral mucous membranes. What action should the nurse implement? A. Discuss the need for medication to treat curd-like oral patches B. Suggest switching the infant’s formula C. Assess the baby’s blood glucose level D. Remind mother not put the baby to bed with propped bottle The father of a 3-day-old infant who is breast feeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cries for no apparent reason. What information is most important for the nurse to provide this father? A. Contact the clinic if the behaviors continue for more than two weeks or become worse B. Tell the father to count the newborn’s number of soiled diapers over the next few days C. A fluctuation in hormones in the early postpartum period can cause mood changes D. Recommend giving supplemental bottle feeding to the baby between breast feeding Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,317 grams), weighs 7 lbs (3,175 grams) today? A. Monitor the stool and urine output of the neonate for the last 24 hours B. Inform and assure the mother that this is a normal weight loss C. Encourage the mother to increase frequency of breastfeeding D. After verifying the accuracy of the weight, notify the HCP A woman who delivered a 9 lb baby boy by cesarean section under spinal anesthesia is recovering in the post anesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous trickle of blood with no clots from the vagina is observed by the nurse. Which action should the nurse implement? A. Massage the fundus vigorously B. Assess her blood pressure C. Apply ice pack to perineum D. Let the infant breast feed A newborn infant is receiving immunization prior to discharge. Which action should the nurse implement? A. Give the first dose of vaccine for rotavirus if any sibling is have diarrhea now. B. Obtain signed consent from the mother from administration hepatitis B vaccine C. Prepare the first dose for diphtheria, tetanus toxoid and acellular pertussis (DTaP) D. Ask the mother if she wants the infant immunized for haemophilus influenzae When teaching a gravid client how to perform kick (fetal movement) counts, which instructions should the nurse include? A. Exercise for 15 minutes before starting the counting to help increase fetal movement B. Count the movement once daily, for one hour, before breakfast C. Avoid caffeinated drinks for 24 hours before conducting the kick test D. If 10 kicks are not felt within one hour, drink orange juice and count for another hour. A client at 38-weeks gestation complains of severe abdominal pain. Upon palpation, the nurse notes that the abdomen is rigid. How should the nurse document the findings? A. Placenta previa B. Oligohydramnios C. Abruptio placenta D. Chorioamnionitis A 26-week gestational primip who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. based on these findings, what action should the nurse implement? A. Notify the HCP of the finding B. Document the finding in the medical record C. Schedule the client of a biophysical profile D. Request another nurse measure the fundus The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress? A. Abdominal breathing with synchronous chest movement B. Shallow and irregular respirations C. Flaring of the nares D. Respiratory rate of 50 breaths per minutes The nurse is caring for laboring client who is GBS+ (Group B streptococcus). Which immediately treatment is indicated for this client? A. Administration of Pitocin B. Artificial rupture of membranes C. Amnioinfusion for the baby D. Administration of antibiotics The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is 0 station. An hour later, she tells the nurse states she wants to go to the bathroom. Which action should the nurse implement first? A. Check the pH of vaginal fluid B. Review the fetal heart rate pattern C. Palpate the client’s bladder D. Determine cervical dilation The nurse’s 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. Position a radiant warmer over B. Assess the infant’s blood glucose level C. Nipple feed 1 ounce 5% glucose water D. Place the infant in a side-lying position Which content should the nurse plan to include in a nutrition class for pregnant adolescents? A. Take iron and calcium supplement daily B. Gain no more than 15 pounds during the pregnancy C. Increase food intake by 300 to 400 calories/day D. Take folic acid supplements daily E. Maintain current protein intake The HCP prescribes 10 units/L of oxytocin via IV drip to augment a clients labor because she is experiencing a prolong active phase. Which finding would cause the nurse to immediately discontinue the oxytocin? A. Uterus is soft B. Contraction duration of 100 seconds C. Four contractions in 10 minutes D. Early deceleration of FHR 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. What action shouldn’t the nurse implement? A. Inform her that a decreased need for insulin occurs while breastfeeding B. Advise the client to breastfeed more frequently C. Counsel her to increase her caloric intake D. Schedule an appointment for the client with the diabetic nurse educator The postpartum admission prescription for a client who delivered a healthy newborn includes one liter of Lactated Ringer’s with oxytocin 20 units to infuse over 8 hours. How many milliunits/minutes is client receiving? 0.4 A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement? A. Schedule weekly perinatal appointments B. Contact social services for a temporary shelter C. Obtain a hemoglobin and hematocrit level D. Have the client transported to the hospital The nurse is planning a class for pregnant women in their first trimester of pregnancy. Which information is most important for the nurse to include in this class? A. Plane rest periods and increase sleep time to 8 hours per day when fatigued B. If any vaginal bleeding occurs, notify the HCP immediately C. Since eating often relieves nausea, carry low-fat snacks to eat whenever nausea occurs. D. If morning dizziness occurs, rise slowly and sit on the side of the bed for one minute When assessing a pregnant woman at 39-weeks gestation who is admitted to labor and delivery, which finding is most important to report to the HCP? A. +1 proteinuria B. 130/70 BP C. +1 pedal edema D. 101.2 F oral temperature A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug. How should the nurse respond? A. You may be at higher risk for having a spontaneous miscarriage B. You may have an increased chance of having preeclampsia C. This medication will have no effect on your unborn child D. You may experience postpartum hemorrhaging after delivery After delivery of a normal infant, the mother tells the nurse that she would like to use oral contraceptives. Which finding in the client’s health history is a contraindication to use of contraceptives? A. Previously used an intrauterine device (IUD) B. Reported history of stroke within the family C. Diagnosed with diabetes mellitus 2 years ago D. Smoke cigarettes prior to becoming pregnant When planning care for a laboring client, the nurse identifies the need to withhold solid foods while the client is in labor. What is the most important reason for this nursing intervention? A. Nausea occurs from analgesic used during labor B. Autonomic nervous system stimulation during labor decreases peristalsis C. An increased risk of aspiration can occur if general anesthesia is needed D. Gastric emptying time decreases during labor The parents of a male newborn have signed an informed consent for circumcision Intervention should the nurse implement upon completion of circumcision. A. Place petrolatum gauze dressings on the site B. Wrap the infant in warm receiving blankets C. Give a PRN dose of liquid acetaminophen D. Offer a pacifier dipped in glucose water At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is she the best time to administer a rubella vaccine to this client? A. After the client stop breastfeeding B. Immediately, at 6-weeks gestation, to protect this fetus C. After the client reaches 20- weeks gestation D. Early postpartum, within 72 hours of delivery The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to the extrauterine life? A. Heart rate of 220 beat/minute B. Cries vigorously when stimulated C. A positive Babinski reflex D. Flexion of all four extremities A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and is dilated 3 cm. the nurse’s assessment findings and electronic fetal monitoring are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor? A. Client’s hourly blood pressure B. Preparation for emergency cesarean birth C. Intensity, interval, and length of contraction D. Checking the perineum for bulging The nurse is caring for a newborn who is 18 inches long, weigh 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. Hyperthermia B. Hyperbilirubinemia C. Polycythemia D. Hypoglycemia A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client? A. When ambulating to void does not cause dizziness B. After the vitamin k injection is given to the baby C. When there is no significant vaginal bleeding D. After the baby no long demonstrates acrocyanosis A client is anovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, Menopur), and human chorionic gonadotropin (hcG). Which side effect should the nurse tell the client to report immediately? A. Episodes of headache and irritability B. Nausea and vomiting C. Rapid increase in abdominal girth D. Persistent daytime fatigue Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse implement first? A. Have the client empty her bladder B. Inspect the perineum for lacerations C. Increase oxytocin IV infusion D. Perform fundal massage until firm