Hesi Maternity EXAM 2 QUESTIONS AND CORRECT ANSWERS
VERIFIED 100%
1.The nurse instructs a laboring client to use accelerated blow breathing. The
client begins to complain of tingling fingers and dizziness. Which action
should the nurse take?
A.
Administer oxygen by facemask.
B.
Notify the health care provider of the client's symptoms.
C.
Have the client breathe into her cupped hands.
D.
Check the client's blood pressure and fetal heart rate.
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much
carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be
facilitated by breathing into a paper bag or cupped hands. Option A is inappropriate
because the carbon dioxide level is low, not the oxygen level. Options B and D are
not specific for this situation.
2.Which findings are most critical for the nurse to report to the primary health
care provider when caring for the client during the last trimester of her
pregnancy? (Select all that apply.)
A. Increased heartburn that is not relieved with doses of antacids
B. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit
C. Shoes and rings that are too tight because of peripheral edema in extremities
D. Decrease in ability for the client to sleep for more than 2 hours at a time
E. Chronic headache that has been lingering for a week behind the client's eyes
Options A and E are possible signs of preeclampsia or eclampsia but can also be
,normal signs of pregnancy. These signs should be reported to the health care
provider for further evaluation for the safety of the client and the fetus. Options B, C,
and D are all normal signs during the last trimester of pregnancy.
3.Twenty minutes after a continuous epidural anesthetic is administered, a
laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which
action should the nurse take immediately?
A. Notify the health care provider or anesthesiologist.
B. Continue to assess the blood pressure every 5 minutes.
C. Place the client in a lateral position.
D. Turn off the continuous epidural.
The nurse should immediately turn the client to a lateral position or place a pillow or
wedge under one hip to deflect the uterus. Other immediate interventions include
increasing the rate of the main line IV infusion and administering oxygen by
facemask. If the blood pressure remains low after these interventions or decreases
further, the anesthesiologist or health care provider should be notified immediately.
To continue to monitor blood pressure without taking further action could constitute
malpractice. Option D may also be warranted, but such action is based on hospital
protocol.
4.The nurse is counseling a client who wants to become pregnant. She tells
the nurse that she has a 36-day menstrual cycle and the first day of her last
menstrual period was January 8. When will the client's next fertile period
occur?
A. January 14 to 15
B. January 22 to 23
C. January 29 to 30
D. February 6 to 7
This client can expect her next period to begin 36 days from the first day of her last
menstrual period. Her next period would begin on February 12. Ovulation occurs 14
days before the first day of the menstrual period. The client can expect ovulation to
occur January 29 to 30. Options A, B, and D are incorrect.
5.Client teaching is an important part of the perinatal nurse's role. Which factor
has the greatest influence on successful teaching of the pregnant client?
, A. The client's investment in what is being taught
B. The couple's highest levels of education
C. The order in which the information is presented
D. The extent to which the pregnancy was planned
When teaching any client, readiness to learn is related to how much the client has
invested in what is being taught or how important the materials are to the client's
particular life. For example, the client with severe morning sickness in the first
trimester may not be ready to learn about labor and delivery but is probably very
ready to learn about ways to relieve morning sickness. Options B and C are factors
that may influence learning but are not as influential as option A. Even if a pregnancy
is planned and very desirable, the client must be ready to learn the content
presented.
6.The client comes to the hospital assuming she is in labor. Which assessment
findings by the nurse would indicate that the client is in true labor? (Select all
that apply.)
A. Pain in the lower back that radiates to abdomen
B. Contractions decreased in frequency with ambulation
C. Progressive cervical dilation and effacement
D. Discomfort localized in the abdomen
E. Regular and rhythmic painful contractions
These are all signs of true labor. Options B and D are signs of false labor.
7. Which maternal behavior is the nurse most likely to see when a new mother
receives her infant for the first time?
A. She eagerly reaches for the infant, undresses the infant, and examines the infant
completely.
B. Her arms and hands receive the infant and she then traces the infant's profile with
her fingertips.
C. Her arms and hands receive the infant and she then cuddles the infant to her own
body.
D. She eagerly reaches for the infant and then holds the infant close to her own
body.
Attachment and bonding theory indicates that most mothers will demonstrate
behaviors described in option B during the first visit with the newborn, which may be
VERIFIED 100%
1.The nurse instructs a laboring client to use accelerated blow breathing. The
client begins to complain of tingling fingers and dizziness. Which action
should the nurse take?
A.
Administer oxygen by facemask.
B.
Notify the health care provider of the client's symptoms.
C.
Have the client breathe into her cupped hands.
D.
Check the client's blood pressure and fetal heart rate.
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much
carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be
facilitated by breathing into a paper bag or cupped hands. Option A is inappropriate
because the carbon dioxide level is low, not the oxygen level. Options B and D are
not specific for this situation.
2.Which findings are most critical for the nurse to report to the primary health
care provider when caring for the client during the last trimester of her
pregnancy? (Select all that apply.)
A. Increased heartburn that is not relieved with doses of antacids
B. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit
C. Shoes and rings that are too tight because of peripheral edema in extremities
D. Decrease in ability for the client to sleep for more than 2 hours at a time
E. Chronic headache that has been lingering for a week behind the client's eyes
Options A and E are possible signs of preeclampsia or eclampsia but can also be
,normal signs of pregnancy. These signs should be reported to the health care
provider for further evaluation for the safety of the client and the fetus. Options B, C,
and D are all normal signs during the last trimester of pregnancy.
3.Twenty minutes after a continuous epidural anesthetic is administered, a
laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which
action should the nurse take immediately?
A. Notify the health care provider or anesthesiologist.
B. Continue to assess the blood pressure every 5 minutes.
C. Place the client in a lateral position.
D. Turn off the continuous epidural.
The nurse should immediately turn the client to a lateral position or place a pillow or
wedge under one hip to deflect the uterus. Other immediate interventions include
increasing the rate of the main line IV infusion and administering oxygen by
facemask. If the blood pressure remains low after these interventions or decreases
further, the anesthesiologist or health care provider should be notified immediately.
To continue to monitor blood pressure without taking further action could constitute
malpractice. Option D may also be warranted, but such action is based on hospital
protocol.
4.The nurse is counseling a client who wants to become pregnant. She tells
the nurse that she has a 36-day menstrual cycle and the first day of her last
menstrual period was January 8. When will the client's next fertile period
occur?
A. January 14 to 15
B. January 22 to 23
C. January 29 to 30
D. February 6 to 7
This client can expect her next period to begin 36 days from the first day of her last
menstrual period. Her next period would begin on February 12. Ovulation occurs 14
days before the first day of the menstrual period. The client can expect ovulation to
occur January 29 to 30. Options A, B, and D are incorrect.
5.Client teaching is an important part of the perinatal nurse's role. Which factor
has the greatest influence on successful teaching of the pregnant client?
, A. The client's investment in what is being taught
B. The couple's highest levels of education
C. The order in which the information is presented
D. The extent to which the pregnancy was planned
When teaching any client, readiness to learn is related to how much the client has
invested in what is being taught or how important the materials are to the client's
particular life. For example, the client with severe morning sickness in the first
trimester may not be ready to learn about labor and delivery but is probably very
ready to learn about ways to relieve morning sickness. Options B and C are factors
that may influence learning but are not as influential as option A. Even if a pregnancy
is planned and very desirable, the client must be ready to learn the content
presented.
6.The client comes to the hospital assuming she is in labor. Which assessment
findings by the nurse would indicate that the client is in true labor? (Select all
that apply.)
A. Pain in the lower back that radiates to abdomen
B. Contractions decreased in frequency with ambulation
C. Progressive cervical dilation and effacement
D. Discomfort localized in the abdomen
E. Regular and rhythmic painful contractions
These are all signs of true labor. Options B and D are signs of false labor.
7. Which maternal behavior is the nurse most likely to see when a new mother
receives her infant for the first time?
A. She eagerly reaches for the infant, undresses the infant, and examines the infant
completely.
B. Her arms and hands receive the infant and she then traces the infant's profile with
her fingertips.
C. Her arms and hands receive the infant and she then cuddles the infant to her own
body.
D. She eagerly reaches for the infant and then holds the infant close to her own
body.
Attachment and bonding theory indicates that most mothers will demonstrate
behaviors described in option B during the first visit with the newborn, which may be
