maternity hesi review
Immediately after birth a newborn infant is suctioned, dried, and placed under a
radiant warmer. The infant has spontaneous respirations and the nurse assesses
an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute.
What action should the nurse perform next?
1 Initiate positive pressure ventilation.
2 Intervene after the one minute Apgar is assessed.
3 Initiate CPR on the infant.
4 Assess the infant's blood glucose level. - CORRECT ANSWER-1. According to
the neonatal resuscitation guidelines, the nurse should immediately begin
positive pressure ventilation because this infant's vital signs are not within the
normal range, and oxygen deprivation leads to cardiac depression in infants.
(The normal newborn pulse is 100 to 160 beats/minute and respirations are 40 to
60 breaths/minute.)
A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started on IV
magnesium sulfate after being diagnosed with severe preeclampsia. After
determining the serum magnesium level to be 15 mEq/L, the nurse should expect
which of the following manifestations in the client?
1 ECG changes.
2 Loss of reflexes.
3 Respiratory distress.
4 Cardiac arrest. - CORRECT ANSWER-3. The therapeutic level of magnesium
sulfate is 4 to 7 mEq/L. ECG changes occur at 5 to 10 mEq/L. Loss of reflexes is
unavoidable at 8 to 12 mEq/L. At 15 mEq/L, the client may experience respiratory
distress. At 25 mEq/L, cardiac arrest may occur
The nurse is performing a gestational age assessment on a full-term newborn
during the first hour of transition using the Ballard (Dubowitz) scale. Based on
this assessment, the nurse determines that the neonate has a maturity rating of
40-weeks. What findings should the nurse identify to determine if the neonate is
small for gestational age (SGA)? (Select all that apply.)
Select all that apply
Some correct answers were not selected
Admission weight of 4 pounds, 15 ounces ( 2244 grams).
, Head to heel length of 17 inches (42.5 cm).
Frontal occipital circumference of 12.5 inches (31.25 cm).
Skin smooth with visible veins and abundant vernix.
Anterior plantar crease and smooth heel surfaces.
Full flexion of all extremities in resting supine position. - CORRECT
ANSWER-1,4,6 The normal full-term, appropriate for gestational age (AGA)
newborn should fall between the measurement ranges of weight, 6-9 pounds
(2700-4000 grams); length, 19-21 inches (48-53 cm); FOC, 13-14 inches (33-35
cm).
A client at 32-weeks gestation is diagnosed with preeclampsia. Which
assessment finding is most indicative of an impending convulsion?
3+ deep tendon reflexes.
Periorbital edema.
Epigastric pain.
Decreased urine output. - CORRECT ANSWER-3. Epigastric pain is indicative of
an edematous liver or pancreas which is an early warning sign of an impending
convulsion in eclampsia and requires immediate attention.
A vaginally delivered infant of an HIV positive mother is admitted to the newborn
nursery. What intervention should the nurse perform first?
Bathe the infant with an antimicrobial soap.
Measure the head and chest circumference.
Obtain the infant's footprints.
Administer vitamin K (AquaMEPHYTON). - CORRECT ANSWER-1. To reduce
direct contact with the human immuno-virus in blood and body fluids on the
newborn's skin, a bath with an antimicrobial soap should be administered first.
A full-term infant is transferred to the nursery from labor and delivery. Which
information is most important for the nurse to receive when planning immediate
care for the newborn?
The length of labor and method of delivery.
The infant's condition at birth and treatment received.
The feeding method chosen by the parents.
The history of drugs given to the mother during labor. - CORRECT ANSWER-2.
Immediate care is most dependent on the infant's current status (i.e., Apgar
scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated.
Immediately after birth a newborn infant is suctioned, dried, and placed under a
radiant warmer. The infant has spontaneous respirations and the nurse assesses
an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute.
What action should the nurse perform next?
1 Initiate positive pressure ventilation.
2 Intervene after the one minute Apgar is assessed.
3 Initiate CPR on the infant.
4 Assess the infant's blood glucose level. - CORRECT ANSWER-1. According to
the neonatal resuscitation guidelines, the nurse should immediately begin
positive pressure ventilation because this infant's vital signs are not within the
normal range, and oxygen deprivation leads to cardiac depression in infants.
(The normal newborn pulse is 100 to 160 beats/minute and respirations are 40 to
60 breaths/minute.)
A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started on IV
magnesium sulfate after being diagnosed with severe preeclampsia. After
determining the serum magnesium level to be 15 mEq/L, the nurse should expect
which of the following manifestations in the client?
1 ECG changes.
2 Loss of reflexes.
3 Respiratory distress.
4 Cardiac arrest. - CORRECT ANSWER-3. The therapeutic level of magnesium
sulfate is 4 to 7 mEq/L. ECG changes occur at 5 to 10 mEq/L. Loss of reflexes is
unavoidable at 8 to 12 mEq/L. At 15 mEq/L, the client may experience respiratory
distress. At 25 mEq/L, cardiac arrest may occur
The nurse is performing a gestational age assessment on a full-term newborn
during the first hour of transition using the Ballard (Dubowitz) scale. Based on
this assessment, the nurse determines that the neonate has a maturity rating of
40-weeks. What findings should the nurse identify to determine if the neonate is
small for gestational age (SGA)? (Select all that apply.)
Select all that apply
Some correct answers were not selected
Admission weight of 4 pounds, 15 ounces ( 2244 grams).
, Head to heel length of 17 inches (42.5 cm).
Frontal occipital circumference of 12.5 inches (31.25 cm).
Skin smooth with visible veins and abundant vernix.
Anterior plantar crease and smooth heel surfaces.
Full flexion of all extremities in resting supine position. - CORRECT
ANSWER-1,4,6 The normal full-term, appropriate for gestational age (AGA)
newborn should fall between the measurement ranges of weight, 6-9 pounds
(2700-4000 grams); length, 19-21 inches (48-53 cm); FOC, 13-14 inches (33-35
cm).
A client at 32-weeks gestation is diagnosed with preeclampsia. Which
assessment finding is most indicative of an impending convulsion?
3+ deep tendon reflexes.
Periorbital edema.
Epigastric pain.
Decreased urine output. - CORRECT ANSWER-3. Epigastric pain is indicative of
an edematous liver or pancreas which is an early warning sign of an impending
convulsion in eclampsia and requires immediate attention.
A vaginally delivered infant of an HIV positive mother is admitted to the newborn
nursery. What intervention should the nurse perform first?
Bathe the infant with an antimicrobial soap.
Measure the head and chest circumference.
Obtain the infant's footprints.
Administer vitamin K (AquaMEPHYTON). - CORRECT ANSWER-1. To reduce
direct contact with the human immuno-virus in blood and body fluids on the
newborn's skin, a bath with an antimicrobial soap should be administered first.
A full-term infant is transferred to the nursery from labor and delivery. Which
information is most important for the nurse to receive when planning immediate
care for the newborn?
The length of labor and method of delivery.
The infant's condition at birth and treatment received.
The feeding method chosen by the parents.
The history of drugs given to the mother during labor. - CORRECT ANSWER-2.
Immediate care is most dependent on the infant's current status (i.e., Apgar
scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated.
