Maternity HESI PACK EXAM GRADED A+ QUESTIONS AND CORRECT ANSWERS 100%
VERIFIED
The nurse is monitoring a client in the immediate postpartum period for signs
of hemorrhage. Which sign, if noted, would be an early sign of excessive blood
loss?
A. A temperature of 100.4 ° F
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths/minute
B. An increase in the pulse rate from 88 to 102 beats/minute
The nurse is preparing a list of self-care instructions for a postpartum client
who was diagnosed with mastitis. Which instructions should be included on
the list? Select all that apply.
A. Wear a supportive bra.
B. Rest during the acute phase.
C. Maintain a fluid intake of at least 3000 mL.
D. Continue to breast-feed if the breasts are not too sore.
E. Take the prescribed antibiotics until the soreness subsides.
F. Avoid decompression of the breasts by breast-feeding or breast pump.
A. Wear a supportive bra.
B. Rest during the acute phase.
C. Maintain a fluid intake of at least 3000 mL.
D. Continue to breast-feed if the breasts are not too sore.
The nurse is providing instructions about measures to prevent postpartum
mastitis to a client who is breast-feeding her newborn. Which client statement
would indicate a need for further instruction?
,A. "I should breast-feed every 2 to 3 hours."
B. "I should change the breast pads frequently."
C. "I should wash my hands well before breast-feeding."
D. "I should wash my nipples daily with soap and water."
D. "I should wash my nipples daily with soap and water."
A client in a postpartum unit complains of sudden sharp chest pain and
dyspnea. The nurse notes that the client is tachycardic and the respiratory rate
is elevated. The nurse suspects a pulmonary embolism. Which should be the
initial nursing action?
A. Initiate an intravenous line.
B. Assess the client's blood pressure.
C. Prepare to administer morphine sulfate.
D. Administer oxygen, 8 to 10 L/minute, by face mask.
D. Administer oxygen, 8 to 10 L/minute, by face mask.
The nurse is assessing a client in the fourth stage of labor and notes that the
fundus is firm, but that bleeding is excessive. Which should be the initial
nursing action?
A. Record the findings.
B. Massage the fundus.
C. Notify the health care provider (HCP).
D. Place the client in Trendelenburg's position.
C. Notify the health care provider (HCP).
The instructor asks a nursing student to list the characteristics of the amniotic
fluid. The student responds correctly by listing which as characteristics of
amniotic fluid? Select all that apply.
A. Allows for fetal movement
B. Surrounds, cushions, and protects the fetus
C. Maintains the body temperature of the fetus
D. Can be used to measure fetal kidney function
E. Prevents large particles such as bacteria from passing to the fetus
, F. Provides an exchange of nutrients and waste products between the mother
and the fetus
A. Allows for fetal movement
B. Surrounds, cushions, and protects the fetus
C. Maintains the body temperature of the fetus
D. Can be used to measure fetal kidney function
Which explanation should the nurse provide to the prenatal client about the
purpose of the placenta?
A. It cushions and protects the baby.
B. It maintains the temperature of the baby.
C. It is the way the baby gets food and oxygen.
D. It prevents all antibodies and viruses from passing to the baby.
C. It is the way the baby gets food and oxygen.
A pregnant client is seen for a regular prenatal visit and tells the nurse that
she is experiencing irregular contractions. The nurse determines that she is
experiencing Braxton Hicks contractions. On the basis of this finding, which
nursing action is most appropriate?
A. Contact the health care provider.
B. Instruct the client to maintain bed rest for the remainder of the pregnancy.
C. Inform the client that these contractions are common and may occur
throughout the pregnancy.
D. Call the maternity unit and inform them that the client will be admitted in a
prelabor condition.
C. Inform the client that these contractions are common and may occur throughout
the pregnancy.
The nurse is collecting data during an admission assessment of a client who is
pregnant with twins. The client has a healthy 5-year-old child who was
delivered at 38 weeks and tells the nurse that she does not have a history of
any type of abortion or fetal demise. Using GTPAL, what should the nurse
document in the client's chart?
A. G=3, T=2, P=O, A=O, L=1
VERIFIED
The nurse is monitoring a client in the immediate postpartum period for signs
of hemorrhage. Which sign, if noted, would be an early sign of excessive blood
loss?
A. A temperature of 100.4 ° F
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths/minute
B. An increase in the pulse rate from 88 to 102 beats/minute
The nurse is preparing a list of self-care instructions for a postpartum client
who was diagnosed with mastitis. Which instructions should be included on
the list? Select all that apply.
A. Wear a supportive bra.
B. Rest during the acute phase.
C. Maintain a fluid intake of at least 3000 mL.
D. Continue to breast-feed if the breasts are not too sore.
E. Take the prescribed antibiotics until the soreness subsides.
F. Avoid decompression of the breasts by breast-feeding or breast pump.
A. Wear a supportive bra.
B. Rest during the acute phase.
C. Maintain a fluid intake of at least 3000 mL.
D. Continue to breast-feed if the breasts are not too sore.
The nurse is providing instructions about measures to prevent postpartum
mastitis to a client who is breast-feeding her newborn. Which client statement
would indicate a need for further instruction?
,A. "I should breast-feed every 2 to 3 hours."
B. "I should change the breast pads frequently."
C. "I should wash my hands well before breast-feeding."
D. "I should wash my nipples daily with soap and water."
D. "I should wash my nipples daily with soap and water."
A client in a postpartum unit complains of sudden sharp chest pain and
dyspnea. The nurse notes that the client is tachycardic and the respiratory rate
is elevated. The nurse suspects a pulmonary embolism. Which should be the
initial nursing action?
A. Initiate an intravenous line.
B. Assess the client's blood pressure.
C. Prepare to administer morphine sulfate.
D. Administer oxygen, 8 to 10 L/minute, by face mask.
D. Administer oxygen, 8 to 10 L/minute, by face mask.
The nurse is assessing a client in the fourth stage of labor and notes that the
fundus is firm, but that bleeding is excessive. Which should be the initial
nursing action?
A. Record the findings.
B. Massage the fundus.
C. Notify the health care provider (HCP).
D. Place the client in Trendelenburg's position.
C. Notify the health care provider (HCP).
The instructor asks a nursing student to list the characteristics of the amniotic
fluid. The student responds correctly by listing which as characteristics of
amniotic fluid? Select all that apply.
A. Allows for fetal movement
B. Surrounds, cushions, and protects the fetus
C. Maintains the body temperature of the fetus
D. Can be used to measure fetal kidney function
E. Prevents large particles such as bacteria from passing to the fetus
, F. Provides an exchange of nutrients and waste products between the mother
and the fetus
A. Allows for fetal movement
B. Surrounds, cushions, and protects the fetus
C. Maintains the body temperature of the fetus
D. Can be used to measure fetal kidney function
Which explanation should the nurse provide to the prenatal client about the
purpose of the placenta?
A. It cushions and protects the baby.
B. It maintains the temperature of the baby.
C. It is the way the baby gets food and oxygen.
D. It prevents all antibodies and viruses from passing to the baby.
C. It is the way the baby gets food and oxygen.
A pregnant client is seen for a regular prenatal visit and tells the nurse that
she is experiencing irregular contractions. The nurse determines that she is
experiencing Braxton Hicks contractions. On the basis of this finding, which
nursing action is most appropriate?
A. Contact the health care provider.
B. Instruct the client to maintain bed rest for the remainder of the pregnancy.
C. Inform the client that these contractions are common and may occur
throughout the pregnancy.
D. Call the maternity unit and inform them that the client will be admitted in a
prelabor condition.
C. Inform the client that these contractions are common and may occur throughout
the pregnancy.
The nurse is collecting data during an admission assessment of a client who is
pregnant with twins. The client has a healthy 5-year-old child who was
delivered at 38 weeks and tells the nurse that she does not have a history of
any type of abortion or fetal demise. Using GTPAL, what should the nurse
document in the client's chart?
A. G=3, T=2, P=O, A=O, L=1
