HESI Maternity Exam 2
n n n
Anprimigravidanasksnthennursenaboutnsignsnshencannlooknfornthatnwouldnindicaten
thatnthenonsetnofnlabornisngettingncloser.nThennursenshouldndescribe:
A) weightngainnofn1nton3nlbs.
B) quickening.
C) fatiguen andn lethargy.
D) bloodynshow.
Thennursenshouldntellnanprimigravidanthatnthendefinitivensignnindicatingnthatnlab
ornhasnbegunnwouldnbe:
A) progressivenuterinencontractionsnwithncervicalnchange.
B) lightening.
C) rupturenofnmembranes.
D) passagen ofn then mucousn plugn (operculum).
Onncompletionnofnanvaginalnexaminationnonnanlaboringnwoman,nthennursenrecord
s:n50%,n6ncm,n-1.nWhatnisnancorrectninterpretationnofnthendata?
A) Thenfetalnpresentingnpartnisn1ncmnaboventhenischialn spines.
B) Effacementnisn4ncmnfromncompletion.
C) Dilationn isn50%n completed.
D) Then fetusn hasn achievedn passagen throughn thenischialn spines.
Innorderntonaccuratelynassessnthenhealthnofnthenmothernaccuratelynduringnlabor,n
thennursenshouldnbenawarenthat:
A) Thenwoman'snbloodnpressurenincreasesnduringncontractionsnandnfallsnbacknto
nprelabornnormalnbetween ncontractions.
B) UsenofnthenValsalvanmaneuvernisnencouragednduringnthensecondnstagenofnla
borntonrelievenfetalnhypoxia.
C) Havingnthenwomannpointnherntoesnreducesnlegncramps.nD
) Then endogenousn endorphinsn releasedn duringn laborn raisen then woman'sn pain
thresholdnandnproducensedation.
Thennursenknowsnthatnthensecondnstagenofnlabor,nthendescentnphase,nhasnbegunn
when:
A) thenamnioticnmembranesnrupture.
B) Thencervixncannotnbenfeltnduringnanvaginalnexamination.
C) Thenwomannexperiencesnanstrongnurgentonbearndown.
D) Thenpresentingnpartnisnbelownthenischialnspines.
Nursesncannhelpntheirnclientsnbynkeepingnthemninformedn aboutnthendistinctive
,stagesnofnlabor.nWhatndescriptionnofnthenphasesnofnthenfirstnstagenofnlabornisnacc
urate?
A) Latent:nmild,nregularncontractions;nnondilation;nbloodynshow;ndurationnofn2
,ton4nhoursnB
) Active:nmoderate,nregularncontractions;n4nton7ncmndilation;ndurationnofn3nto
6nhours
C) Lull:nnoncontractions;ndilationnstable;ndurationnofn20nton60nminutes
D) Transition:nverynstrongnbutnirregularncontractions;n8nton10ncmndilation;nd
urationnofn1nton2nhours
Whichnpositionnwouldnthennursensuggestnfornsecond-
stagenlabornifnthenpelvicnoutletnneedsntonbenincreased?
A) Semirecumbent
B) Sittingn C)n
Squatting
D)n Side-lying
Concerningnthenthirdnstagenofnlabor,nnursesnshouldnbenawarenthat:
A) thenplacentaneventuallyndetachesnitselfnfromnanflaccidnuterus
B) Thendurationnofnthenthirdnstagenmaynbenasnshortnasn3nton5nminutes
C) itnisnimportantnthatnthendark,nroughenednmaternalnsurfacenofnthenplacentana
ppearnbeforenthenshinynfetalnsurface
D) thenmajornrisknfornwomennduringnthenthirdnstagenisnanrapidnheartnrate
Thenchargennursenonnthenmaternitynunitnisnorientingnannewnnursentonthenunitnand
nexplains nthatnthen5nPsnofnlabornandnbirthnare: n(Select nallnthatnapply.)
A) passenger.
B) placenta.
F)nposition.
Nursesncannadvisentheirnpatientsnthatnwhichnofnthesensignsnprecedenlabor?n(Sele
ctnallnthatnapply.)
C.
D.n Andeclineninnenergy,nasnthenbodynstoresnupnfornlaborn E
. Uterusnsinksndownwardnandnforwardninnfirst-timenpregnancies.
Thenmaternitynnursenshouldnnotifynthenhealthncarenprovidernaboutnwhichnassess
mentnfindingsnduringnlabor?n(Selectnallnthatnapply.)
A. Positiven urinendrugn screen
B. Bloodnglucosen levelnofn78nmg/dL
C. Increasedn systolicn bloodn pressuren duringn firstn stage
, D. Elevatednwhitenbloodncellncount
E. Oralntemperaturenofn99.8°nF
F. Respiratorynratenofn10nbreaths/min
Anlaboringnwomannbecomesnanxiousnduringnthentransitionnphasenofnthenfirstnstag
enofnlabornandndevelopsnanrapidnandndeepnrespiratorynpattern.nShencomplainsnofn
feelingndizzynandnlight-headed.nThennurse'snimmediatenresponsenwouldnbento:
A. encouragenthenwomanntonbreathenmorenslowly.
B. helpn then womann breathen intonan papern bag.
C. turnnthenwomannonnhernside.
D. administernansedative.
Anwomannisninnthensecondnstagenofnlabornandnhasnanspinalnblockninnplacenfornpa
innmanagement.nThennursenobtainsnthenwoman'snbloodnpressurenandnnotesnthatni
tnisn20%nlowernthannthenbaselinenlevel.nWhichnactionnshouldnthennursentake?
A. Encouragenherntonemptynhernbladder.
B. Decreasenhernintravenousn(IV)nratentonankeepn vein-opennrate.
C. Turnnthenwomanntonthenleftnlateralnpositionnornplacenanpillownundernhernhip.
D. Nonactionnisnnecessarynsincenandecreaseninnthenwoman'snbloodnpressurenisne
xpected.
Anwomanninnlatentnlabornwhonisnpositivenfornopiatesnonnthenurinendrugnscreennisnc
omplainingnofnseverenpain.nMaternalnvitalnsignsnarenstable,nandnthenfetalnheartn
monitorndisplaysnanreassuringnpattern.nThennurse'snMOSTnappropriatenanalgesicn
fornpainncontrolnis:
A. fentanyln(Sublimaze).nB.pr
omethazinen(Phenergan).
C.n butorphanoln tartraten (Stadol).
D.nnalbuphinen(Nubain).
Anwomannisnexperiencingnbacknlabornandncomplainsnofnconstant,nintensenpainnin
nhernlowernback. nAnneffective nreliefnmeasure nisntonuse:
A.n counterpressuren againstn then sacrum.
B.n pant-blown(breathsnandnpuffs)nbreathingntechniques.
C.n effleurage.
D.n biofeedback.
n n n
Anprimigravidanasksnthennursenaboutnsignsnshencannlooknfornthatnwouldnindicaten
thatnthenonsetnofnlabornisngettingncloser.nThennursenshouldndescribe:
A) weightngainnofn1nton3nlbs.
B) quickening.
C) fatiguen andn lethargy.
D) bloodynshow.
Thennursenshouldntellnanprimigravidanthatnthendefinitivensignnindicatingnthatnlab
ornhasnbegunnwouldnbe:
A) progressivenuterinencontractionsnwithncervicalnchange.
B) lightening.
C) rupturenofnmembranes.
D) passagen ofn then mucousn plugn (operculum).
Onncompletionnofnanvaginalnexaminationnonnanlaboringnwoman,nthennursenrecord
s:n50%,n6ncm,n-1.nWhatnisnancorrectninterpretationnofnthendata?
A) Thenfetalnpresentingnpartnisn1ncmnaboventhenischialn spines.
B) Effacementnisn4ncmnfromncompletion.
C) Dilationn isn50%n completed.
D) Then fetusn hasn achievedn passagen throughn thenischialn spines.
Innorderntonaccuratelynassessnthenhealthnofnthenmothernaccuratelynduringnlabor,n
thennursenshouldnbenawarenthat:
A) Thenwoman'snbloodnpressurenincreasesnduringncontractionsnandnfallsnbacknto
nprelabornnormalnbetween ncontractions.
B) UsenofnthenValsalvanmaneuvernisnencouragednduringnthensecondnstagenofnla
borntonrelievenfetalnhypoxia.
C) Havingnthenwomannpointnherntoesnreducesnlegncramps.nD
) Then endogenousn endorphinsn releasedn duringn laborn raisen then woman'sn pain
thresholdnandnproducensedation.
Thennursenknowsnthatnthensecondnstagenofnlabor,nthendescentnphase,nhasnbegunn
when:
A) thenamnioticnmembranesnrupture.
B) Thencervixncannotnbenfeltnduringnanvaginalnexamination.
C) Thenwomannexperiencesnanstrongnurgentonbearndown.
D) Thenpresentingnpartnisnbelownthenischialnspines.
Nursesncannhelpntheirnclientsnbynkeepingnthemninformedn aboutnthendistinctive
,stagesnofnlabor.nWhatndescriptionnofnthenphasesnofnthenfirstnstagenofnlabornisnacc
urate?
A) Latent:nmild,nregularncontractions;nnondilation;nbloodynshow;ndurationnofn2
,ton4nhoursnB
) Active:nmoderate,nregularncontractions;n4nton7ncmndilation;ndurationnofn3nto
6nhours
C) Lull:nnoncontractions;ndilationnstable;ndurationnofn20nton60nminutes
D) Transition:nverynstrongnbutnirregularncontractions;n8nton10ncmndilation;nd
urationnofn1nton2nhours
Whichnpositionnwouldnthennursensuggestnfornsecond-
stagenlabornifnthenpelvicnoutletnneedsntonbenincreased?
A) Semirecumbent
B) Sittingn C)n
Squatting
D)n Side-lying
Concerningnthenthirdnstagenofnlabor,nnursesnshouldnbenawarenthat:
A) thenplacentaneventuallyndetachesnitselfnfromnanflaccidnuterus
B) Thendurationnofnthenthirdnstagenmaynbenasnshortnasn3nton5nminutes
C) itnisnimportantnthatnthendark,nroughenednmaternalnsurfacenofnthenplacentana
ppearnbeforenthenshinynfetalnsurface
D) thenmajornrisknfornwomennduringnthenthirdnstagenisnanrapidnheartnrate
Thenchargennursenonnthenmaternitynunitnisnorientingnannewnnursentonthenunitnand
nexplains nthatnthen5nPsnofnlabornandnbirthnare: n(Select nallnthatnapply.)
A) passenger.
B) placenta.
F)nposition.
Nursesncannadvisentheirnpatientsnthatnwhichnofnthesensignsnprecedenlabor?n(Sele
ctnallnthatnapply.)
C.
D.n Andeclineninnenergy,nasnthenbodynstoresnupnfornlaborn E
. Uterusnsinksndownwardnandnforwardninnfirst-timenpregnancies.
Thenmaternitynnursenshouldnnotifynthenhealthncarenprovidernaboutnwhichnassess
mentnfindingsnduringnlabor?n(Selectnallnthatnapply.)
A. Positiven urinendrugn screen
B. Bloodnglucosen levelnofn78nmg/dL
C. Increasedn systolicn bloodn pressuren duringn firstn stage
, D. Elevatednwhitenbloodncellncount
E. Oralntemperaturenofn99.8°nF
F. Respiratorynratenofn10nbreaths/min
Anlaboringnwomannbecomesnanxiousnduringnthentransitionnphasenofnthenfirstnstag
enofnlabornandndevelopsnanrapidnandndeepnrespiratorynpattern.nShencomplainsnofn
feelingndizzynandnlight-headed.nThennurse'snimmediatenresponsenwouldnbento:
A. encouragenthenwomanntonbreathenmorenslowly.
B. helpn then womann breathen intonan papern bag.
C. turnnthenwomannonnhernside.
D. administernansedative.
Anwomannisninnthensecondnstagenofnlabornandnhasnanspinalnblockninnplacenfornpa
innmanagement.nThennursenobtainsnthenwoman'snbloodnpressurenandnnotesnthatni
tnisn20%nlowernthannthenbaselinenlevel.nWhichnactionnshouldnthennursentake?
A. Encouragenherntonemptynhernbladder.
B. Decreasenhernintravenousn(IV)nratentonankeepn vein-opennrate.
C. Turnnthenwomanntonthenleftnlateralnpositionnornplacenanpillownundernhernhip.
D. Nonactionnisnnecessarynsincenandecreaseninnthenwoman'snbloodnpressurenisne
xpected.
Anwomanninnlatentnlabornwhonisnpositivenfornopiatesnonnthenurinendrugnscreennisnc
omplainingnofnseverenpain.nMaternalnvitalnsignsnarenstable,nandnthenfetalnheartn
monitorndisplaysnanreassuringnpattern.nThennurse'snMOSTnappropriatenanalgesicn
fornpainncontrolnis:
A. fentanyln(Sublimaze).nB.pr
omethazinen(Phenergan).
C.n butorphanoln tartraten (Stadol).
D.nnalbuphinen(Nubain).
Anwomannisnexperiencingnbacknlabornandncomplainsnofnconstant,nintensenpainnin
nhernlowernback. nAnneffective nreliefnmeasure nisntonuse:
A.n counterpressuren againstn then sacrum.
B.n pant-blown(breathsnandnpuffs)nbreathingntechniques.
C.n effleurage.
D.n biofeedback.
