HESI Maternity/PEDS 2024

HESI Maternity/PEDS A 3-month-old with myelomeningocele and atonic bladder is catheterized every four hours to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria,, watery eyes, ad a rash in the diaper area. What action is most important for the nurse to take? Change to latex - free gloves when handling infant The 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated? Crying without tears A 6-year old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is most important for the nurse to implement? Assess bilateral lung sounds A 34-week primigravida with preeclampsia is receiving Lactated Ringer's 500 ML with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many mL/hour should be the nurse program into the infusion pump? 75mL/hour A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? Notify healthcare provider at patients' bedside A 39 week gestation, a multigravida is having a non-stress test (NST). The fetal heart rate (FHR) has remained non- reactive during the 30 minutes of evaluation. Based on this finding, which action should the nurse implement? Place an acoustic simulator on the abdomen. Artificial rupture of the membranes of a laboring client reveals meconium- stained fluid. What intervention has the greatest priority? Have a meconium aspirator available at delivery At 20 weeks gestation, a client who has gained 20 pounds during pregnant states that she is felling fetal movement. Fundal height measurement is 20 cm, and the clients only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation? Gestational weight gain. A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.2 F, with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of what condition? Chorioamnionitis A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. What information is most important foe the nurse to obtain first? Color and consistency of fluid A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what information is most important for the nurse to provide? Maternal blood pressure