HESI PN MATERNITY EXAM QUESTIONS AND ANSWERS WITH RATIONALES 2023

During labor, the fetal heart rate slowly decelerates at the beginning of the contraction and returns to baseline at the end of the contraction. What action should the nurse take? a. Turn the mother to her left side. b. Administer oxygen to the mother via face mask. c. Notify the health care provider regarding the findings. d. Continue to monitor the progress of the client’s labor. D) Continue to monitor the progress of the client’s labor. Rationale: Early decelerations during labor are frequently caused by head compression within the uterus, and no nursing intervention is required except to monitor the mother’s progress during labor. Which maternal behavior is the practical nurse (PN) most likely to see when a new mother receives her infant for the first time? a. She eagerly undresses the infant and examines the infant completely. b. She receives the infant and touches the infant’s face with her fingertips. c. She reaches and cuddles the infant to her own body. d. She reaches but hesitates for the nurse’s encouragement. B) She receives the infant and touches the infant’s face with her fingertips. Rationale: Attachment/bonding theory indicates that most mothers will touch the infant’s face during the first visit with the newborn.A new father asks the practical nurse (PN) why ointment is instilled into the eyes of his newborn infant. Which infection should the PN identify when describing the purpose of this treatment? a. Herpes b. Staphylococcus c. Gonorrhea d. Syphilis C) Gonorrhea Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The nurse is taking the temperature of a client who is 6 hours postpartum. The nurse notes that the client’s temperature is 38° C (100.4° F). Which intervention should the nurse implement? a. Encourage fluids to increase hydration. b. Recheck the temperature in 15 minutes. c. Place an ice pack on the client’s forehead. d. Obtain a prescription for acetaminophen. A) Encourage fluids to increase hydration. Rationale: It is normal for the postpartum client to have a temperature up to 38° C (100.4° F) because of dehydration caused by labor. The most appropriate intervention is to encourage fluids to rehydrate the patient.*Above 38° C (100.4° F) is critical A newborn infant is breathing satisfactorily but appears dusky. What action should the practical nurse (PN) take first? a. Notify the pediatrician immediately. b. Suction the infant’s nares and then the oral cavity. c. Check the infant’s oxygen saturation rate. d. Position the infant on the right side. C) Check the infant’s oxygen saturation rate. Rationale: The PN should first obtain measurable objective data; an oxygen saturation rate provides such information. The pediatrician should be notified if the oxygen saturation rate is below 90%. The practical nurse (PN) caring for a laboring client encourages her to void at least every 2 hours and records each time the client empties her bladder. What is the rationale for implementing this nursing intervention? a. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part b. An overdistended bladder could be traumatized during labor and could prolong the progress of labor. c. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. d. Frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection. B) An overdistended bladder could be traumatized during labor and could prolong the progress of labor. Rationale:A full bladder can impair the efficiency of the uterine contractions and impede descent of the fetus during labor. Also, because of the close proximity of the bladder to the uterus, the bladder can be traumatized by the descent of the fetus.