Answers from HESI test taken on Oct. 20th 2021 i i i i i i i i
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1. A client at 37 weeks gestation presents to labor and delivery with contractions
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every two minutes the nurse observes several shallow small vesicles on her
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pubis labia and perineum. the nurse should recognize the clients is prohibiting
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symptoms of which condition?
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1. German measles i
2. herpes simplex virus i i
3. syphilis
4. genital warts i
4. A client who had her first baby three months ago and is breastfeeding her infant
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tells the nurse that she is currently using the same diaphragm that she used before
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becoming pregnant. Which information should the nurse provide this client?
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Use alternative form of birth control until new diaphragm can be
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obtained.
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7. A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour
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labor. What is the priority nursing action for this client?
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Massage the fundus Q 4 hours i i i i i
9. At 0600 while admitting a woman for a scheduled repeat cesarean section (C-
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Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
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wanted to avoid getting a headache. Which action should the nurse take first?
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Inform the anesthesia care provider i i i i
,10. The nurse is caring for a postpartum client who is exhibiting symptoms of a
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spinal headache 24 hours following delivery of a normal newborn. Prior to the
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anesthesiologist arrival on the unit, which action should the nurse perform?
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- Place procedure equipment at bedside
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11. The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14
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ounces, has a head circumference of 13 inches, and a chest circumference of 10
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inches. Based on these physical findings, assessment for which condition has the
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highest priority?
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Hypoglycemia
13. the nurse is caring for a 35 week gestation infant delivered by cesarean section2
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hours ago. the nurse observes the infants respiratory rate is 72 breaths minute with
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nasal flaring, grunting, and retractions. the nurse should recognize these finding
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indicate which complication?
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- B – transient tachypnea of the newborn
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14. A primipara client at 42 weeks gestation is admitted for induction. within one
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hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm
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dilated, contractions are occuring every 1 minute with a 75 second duration. when
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nurse stops the oxytocin and starts oxygen. after 30 minutes of uterine rest, the
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contractions are occuring every 5 minutes with 20 second duration. which
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intervention should the nurse implement?
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Restart the oxytocin per oxytocin protocol i i i i i
, 15. A primigravida arrives at the observation unit of the maternity unit because she
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thinks she is in labor. the nurse applies the external fetal heart monitor and
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determines she is not in labor. What makes the nurse realize she is not in labor?
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Contractions stop when the client is walking i i i i i i
16. A primigravida client with gestational hypertension and bishop score of 3 is
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scheduled for induction of labor. the nurse administers misoprostol at 0700 then
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observes regular contractions with cervical changes at 0900 which action should
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the nurse take?
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- Administer oxytocin 4 hours later
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17. A multigravida client in labor is receiving oxytocin Pitocin 4mu/minute to help
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promote an effective contraction pattern. The available solution is Lactated Ringers
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1,000 ml with Pitocin 20 units. The nurse should program the infusion pump to
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deliver how many ml/hr?
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12
18. The nurse is caring for a client whose fetus died in utero at 32 weeks gestation.
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After the fetus is delivered vaginally, the nurse implements routine demise protocol
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and identification procedures. What action is most important for the nurse to take?
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Encourage the mother to hold and spend time with her baby i i i i i i i i i i
19. Following a minor vehicle collision, a client 36 weeks gestation is brought to
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the emergency center. She is lying supine on a backboard , is awake , denies any
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complaints. Her blood pressure is 80/50 mm Hg and heart rate is 130 beats per
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min. What action should the nurse implement first?
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Turn the board sideways to displace the uterus lateral
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20. A new mother asks the nurse about an area of swelling on her baby's head near
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the posterior fontanel that lies across the suture line. How should the nurse respond?
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