MILESTONE 2 HESI MATERNITY REMEDIATION
1. During stage two of A. Fetal heart rate before the contraction
labor, what assess- B. Fetal heart rate during the contraction
ments must the la- C. Fetal heart rate after the contraction
bor nurse perform? D. Frequency of contractions
(Select all that ap- E. Duration of contractions
ply.) F. Uterine tone between contractions
Rationale:The nurse must assess the fetal heart rate before, during and after
the contractions to determine the fetal response to the contractions. Frequency
may slow during the second stage. Duration will help facilitate decent of the
presenting part. The uterine tone between contractions should be soft to
facilitate placental filling after the contraction.
2. The nurse is pro- A. Vernix in the creases of the neck
viding care to a E. Labia majora covers the labia minora.
1-hour-old infant. Rationale:Vernix in neck creases and the labia majora covering the labia minora
An assessment of are signs of a term infant. Lanugo covering the back, foot creases anterior third
gestational age is and breast tissue less than 0.75 cm are assessment findings associated with
performed and the preterm infants.
nurse estimates the
age at 39 to 40
weeks. What find-
ings will the nurse
document in the in-
fant's chart? (Select
all that apply.)
3. The nurse is dis- B. "I do not want to be a father!"
cussing many of the E. "I am sure I am not the father of this baby."
changes a pregnan- Rationale:It is normal for the father to express feelings of ambivalence towards
cy brings to a cou- fatherhood, and sharing his wife's attention. Concerning statements include
ple. Which of the denial of fatherhood.
father's statements
1/6
, MILESTONE 2 HESI MATERNITY REMEDIATION
concerns the nurse
the most? (Select all
that apply.)
A."I am not sure I
know how to be a
father."
4. The nurse is teach- A."The baby has to pass through the true pelvis."
ing a prenatal class B."The pelvis consists of three distinct features."
about the struc- C."The true pelvis is below the pelvic brim."
ture of the pelvis D."The ischial spines determine how low the baby is located."
and is using a Rationale:A gynecoid shape pelvis is the most favorable for birthing. The re-
model of a pelvis maining statements are true.
in the presentation.
Which statements
will the nurse in-
clude in the teach-
ing plan? (Select all
that apply.)
5. The nurse is pro- A.Massage the fundus.
viding care for a Rationale:These are signs that the placenta has separated from the uterus.
woman who just Implement interventions that would promote the uterus to contract, such as
delivered. The um- massaging the fundus or placing the infant to breast. If oxytocin is in use,
bilical cord extends the health care provider may prescribe a rapid infusion of oxytocin. This is a
from the vagina normal finding with the delivery of the placenta. The increase in blood volume
accompanied by a with pregnancy accommodates this gush of blood and therefore the blood
gush of blood. pressure will not be impacted. There is no indication in the normal scenario
What is the next that a catheter is indicated. It can take up to 30 minutes for the uterus to release
nursing action? the placenta. The second Apgar needs to be assessed at 5 minutes after birth
6.
2/6
1. During stage two of A. Fetal heart rate before the contraction
labor, what assess- B. Fetal heart rate during the contraction
ments must the la- C. Fetal heart rate after the contraction
bor nurse perform? D. Frequency of contractions
(Select all that ap- E. Duration of contractions
ply.) F. Uterine tone between contractions
Rationale:The nurse must assess the fetal heart rate before, during and after
the contractions to determine the fetal response to the contractions. Frequency
may slow during the second stage. Duration will help facilitate decent of the
presenting part. The uterine tone between contractions should be soft to
facilitate placental filling after the contraction.
2. The nurse is pro- A. Vernix in the creases of the neck
viding care to a E. Labia majora covers the labia minora.
1-hour-old infant. Rationale:Vernix in neck creases and the labia majora covering the labia minora
An assessment of are signs of a term infant. Lanugo covering the back, foot creases anterior third
gestational age is and breast tissue less than 0.75 cm are assessment findings associated with
performed and the preterm infants.
nurse estimates the
age at 39 to 40
weeks. What find-
ings will the nurse
document in the in-
fant's chart? (Select
all that apply.)
3. The nurse is dis- B. "I do not want to be a father!"
cussing many of the E. "I am sure I am not the father of this baby."
changes a pregnan- Rationale:It is normal for the father to express feelings of ambivalence towards
cy brings to a cou- fatherhood, and sharing his wife's attention. Concerning statements include
ple. Which of the denial of fatherhood.
father's statements
1/6
, MILESTONE 2 HESI MATERNITY REMEDIATION
concerns the nurse
the most? (Select all
that apply.)
A."I am not sure I
know how to be a
father."
4. The nurse is teach- A."The baby has to pass through the true pelvis."
ing a prenatal class B."The pelvis consists of three distinct features."
about the struc- C."The true pelvis is below the pelvic brim."
ture of the pelvis D."The ischial spines determine how low the baby is located."
and is using a Rationale:A gynecoid shape pelvis is the most favorable for birthing. The re-
model of a pelvis maining statements are true.
in the presentation.
Which statements
will the nurse in-
clude in the teach-
ing plan? (Select all
that apply.)
5. The nurse is pro- A.Massage the fundus.
viding care for a Rationale:These are signs that the placenta has separated from the uterus.
woman who just Implement interventions that would promote the uterus to contract, such as
delivered. The um- massaging the fundus or placing the infant to breast. If oxytocin is in use,
bilical cord extends the health care provider may prescribe a rapid infusion of oxytocin. This is a
from the vagina normal finding with the delivery of the placenta. The increase in blood volume
accompanied by a with pregnancy accommodates this gush of blood and therefore the blood
gush of blood. pressure will not be impacted. There is no indication in the normal scenario
What is the next that a catheter is indicated. It can take up to 30 minutes for the uterus to release
nursing action? the placenta. The second Apgar needs to be assessed at 5 minutes after birth
6.
2/6
