Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
An expectant father tells the nurse he
fears that his wife is "losing her mind."
He states that she is constantly rubbing
her abdomen and talking to the baby and D) Reassure him that normal mater-
that she actually reprimands the baby nal-fetal bonding is occurring.
when it moves too much. Which recom-
mendation should the nurse make to this Rationale:
expectant father? These behaviors are positive signs of
maternal-fetal bonding and do not reflect
A.Suggest that his wife seek profession- ambivalence. No intervention is needed.
al counseling to deal with her symptoms. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks
B.Explain that his wife is exhibiting am- of gestation and begins a new phase
bivalence about the pregnancy. of prenatal bonding during the second
trimester. Options A and C are not nec-
C. Ask him to report similar abnormal essary because the behaviors displayed
behaviors at the next prenatal visit. are normal.
D.Reassure him that normal maternal-fe-
tal bonding is occurring.
C. Fetal heart rate (FHR)
Rationale:
The nurse is preparing a laboring client
The FHR should be assessed before and
for an amniotomy. Immediately after the
after the procedure to detect changes
procedure is completed, it is most impor-
that may indicate the presence of cord
tant for the nurse to obtain which infor-
compression or prolapse. An amniotomy
mation?
(artificial rupture of membranes [AROM])
is used to stimulate labor when the con-
A.Maternal blood pressure
dition of the cervix is favorable. The flu-
id should be assessed for color, odor,
B.Maternal temperature
and consistency. Option A should be as-
sessed every 15 to 20 minutes during la-
C.Fetal heart rate (FHR)
bor but is not specific for AROM. Option B
is monitored hourly after the membranes
D.White blood cell count (WBC)
are ruptured to detect the development
of amnionitis. Option D should be deter-
mined for all clients in labor.
A nurse receives a shift change report for
a newborn who is 12 hours post-vaginal
delivery. In developing a plan of care, the
nurse should give the highest priority to
which finding?
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin col-
oration, is caused by elevated levels of
bilirubin, which should be further evalu-
ated in a newborn <24 hours old. Acro-
cyanosis (blue color of the hands and
feet) is a common finding in newborns;
it occurs because the capillary system is
immature. Milia are small white papules
present on the nose and chin that are
caused by sebaceous gland blockage
and disappear in a few weeks. Small red
patches on the cheeks and trunk are
called erythema toxicum neonatorum, a
common finding in newborns.
A breastfeeding postpartum client is di-
agnosed with mastitis, and antibiotic
therapy is prescribed. Which instruction A.Breastfeed the infant, ensuring that
should the nurse provide to this client? both breasts are completely emptied.
A.Breastfeed the infant, ensuring that Rationale:Mastitis, caused by plugged
both breasts are completely emptied. milk ducts, is related to breast engorge-
ment, and breastfeeding during mastitis
B.Feed expressed breast milk to avoid facilitates the complete emptying of en-
the pain of the infant latching onto the gorged breasts, eliminating the pressure
infected breast. on the inflamed breast tissue. Option B is
less painful but does not facilitate com-
C.Breastfeed on the unaffected breast plete emptying of the breast tissue. Op-
only until the mastitis subsides. tion C will not relieve the engorgement
on the affected side. Option D will not
D.Dilute expressed breast milk with ster- decrease antibiotic effects on the infant.
ile water to reduce the antibiotic effect on
the infant.
C.Move about every hour.
A 38-week primigravida who works as a
secretary and sits at a computer 8 hours
Rationale:
each day tells the nurse that her feet
Pooling of blood in the lower extremities
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
results from the enlarged uterus exert-
have begun to swell. Which instruction ing pressure on the pelvic veins. Moving
will aid in the prevention of pooling of about every hour will relieve pressure
blood in the lower extremities? on the pelvic veins and increase venous
return. Option A would increase venous
A.Wear support stockings. return from varicose veins in the lower
extremities but would be of little help with
B.Reduce salt in the diet. swelling. Option B might be helpful with
generalized edema but is not specific
C.Move about every hour. for edematous lower extremities. Option
D does not address venous return, and
D.Avoid constrictive clothing. there is no indication in the question that
constrictive clothing is a problem.
Twenty-four hours after admission to the
newborn nursery, a full-term male infant
develops localized swelling on the right
A.Cephalhematoma, which is caused by
side of his head. In a newborn, what is
forceps trauma
the most likely cause of this accumu-
lation of blood between the periosteum
Rationale: Cephalhematoma, a slight ab-
and skull that does not cross the suture
normal variation of the newborn, usually
line?
arises within the first 24 hours after de-
livery. Trauma from delivery causes cap-
A.Cephalhematoma, which is caused by
illary bleeding between the periosteum
forceps trauma
and skull. Option C is a cranial distortion
lasting 5 to 7 days, caused by pressure
B.Subarachnoid hematoma, which re-
on the cranium during vaginal delivery,
quires immediate drainage
and is a common variation of the new-
born. Options B and D both involve in-
C.Molding, which is caused by pressure
tracranial bleeding and could not be de-
during labor
tected by physical assessment alone.
D.Subdural hematoma, which can result
in lifelong damage
Prior to discharge, what instructions
should the nurse give to parents regard- C.Allow the cord to air-dry as much as
ing the newborn's umbilical cord care at possible.
home?
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
A.Wash the cord frequently with mild
soap and water.
Rationale:Recent studies have indicated
that air drying or plain water application
B.Cover the cord with a sterile dressing.
may be equal to or more effective than
alcohol in the cord healing process. Op-
C.Allow the cord to air-dry as much as
tions A, B, and D are incorrect because
possible.
they promote moisture and increase the
potential for infection.
D.Apply baby lotion after the baby's daily
bath
C.Place petroleum ointment around the
A mother expresses fear about chang-
glans with each diaper change and
ing the infant's diaper after circumcision.
cleansing.
What information should the nurse in-
clude in the teaching plan?
Rationale:
With each diaper change, the glans pe-
A.Cleanse the penis with prepackaged
nis should be washed with warm water to
diaper wipes every 3 to 4 hours.
remove any urine or feces, and petrole-
um ointment should be applied to prevent
B.Wash off the yellow exudate on the
the diaper from sticking to the healing
glans once every day to prevent infec-
surface. Prepackaged wipes often con-
tion.
tain other products that may irritate the
site. The yellow exudate, which covers
C.Place petroleum ointment around
the glans penis as the area heals and
the glans with each diaper change and
epithelializes, is not an infective process
cleansing.
and should not be removed. If bleeding
occurs at home, the client should be in-
D.Apply pressure by squeezing the pe-
structed to apply gentle pressure to the
nis with the fingers for 5 minutes if bleed-
site of the bleeding with sterile gauze
ing occurs.
squares and call the health care provider.
A 26-year-old gravida 2, para 1, client
is admitted to the hospital at 28 weeks
C.Tachycardia and a feeling of nervous-
of gestation in preterm labor. She is
ness
given three doses of terbutaline sulfate
(Brethine), 0.25 mg subcutaneously, to
Rationale: Terbutaline sulfate (Brethine),
stop her labor contractions. What are the
a beta-sympathomimetic drug, stimu-
primary side effects of terbutaline sul-
fate?
Study online at https://quizlet.com/_9fcccz
An expectant father tells the nurse he
fears that his wife is "losing her mind."
He states that she is constantly rubbing
her abdomen and talking to the baby and D) Reassure him that normal mater-
that she actually reprimands the baby nal-fetal bonding is occurring.
when it moves too much. Which recom-
mendation should the nurse make to this Rationale:
expectant father? These behaviors are positive signs of
maternal-fetal bonding and do not reflect
A.Suggest that his wife seek profession- ambivalence. No intervention is needed.
al counseling to deal with her symptoms. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks
B.Explain that his wife is exhibiting am- of gestation and begins a new phase
bivalence about the pregnancy. of prenatal bonding during the second
trimester. Options A and C are not nec-
C. Ask him to report similar abnormal essary because the behaviors displayed
behaviors at the next prenatal visit. are normal.
D.Reassure him that normal maternal-fe-
tal bonding is occurring.
C. Fetal heart rate (FHR)
Rationale:
The nurse is preparing a laboring client
The FHR should be assessed before and
for an amniotomy. Immediately after the
after the procedure to detect changes
procedure is completed, it is most impor-
that may indicate the presence of cord
tant for the nurse to obtain which infor-
compression or prolapse. An amniotomy
mation?
(artificial rupture of membranes [AROM])
is used to stimulate labor when the con-
A.Maternal blood pressure
dition of the cervix is favorable. The flu-
id should be assessed for color, odor,
B.Maternal temperature
and consistency. Option A should be as-
sessed every 15 to 20 minutes during la-
C.Fetal heart rate (FHR)
bor but is not specific for AROM. Option B
is monitored hourly after the membranes
D.White blood cell count (WBC)
are ruptured to detect the development
of amnionitis. Option D should be deter-
mined for all clients in labor.
A nurse receives a shift change report for
a newborn who is 12 hours post-vaginal
delivery. In developing a plan of care, the
nurse should give the highest priority to
which finding?
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin col-
oration, is caused by elevated levels of
bilirubin, which should be further evalu-
ated in a newborn <24 hours old. Acro-
cyanosis (blue color of the hands and
feet) is a common finding in newborns;
it occurs because the capillary system is
immature. Milia are small white papules
present on the nose and chin that are
caused by sebaceous gland blockage
and disappear in a few weeks. Small red
patches on the cheeks and trunk are
called erythema toxicum neonatorum, a
common finding in newborns.
A breastfeeding postpartum client is di-
agnosed with mastitis, and antibiotic
therapy is prescribed. Which instruction A.Breastfeed the infant, ensuring that
should the nurse provide to this client? both breasts are completely emptied.
A.Breastfeed the infant, ensuring that Rationale:Mastitis, caused by plugged
both breasts are completely emptied. milk ducts, is related to breast engorge-
ment, and breastfeeding during mastitis
B.Feed expressed breast milk to avoid facilitates the complete emptying of en-
the pain of the infant latching onto the gorged breasts, eliminating the pressure
infected breast. on the inflamed breast tissue. Option B is
less painful but does not facilitate com-
C.Breastfeed on the unaffected breast plete emptying of the breast tissue. Op-
only until the mastitis subsides. tion C will not relieve the engorgement
on the affected side. Option D will not
D.Dilute expressed breast milk with ster- decrease antibiotic effects on the infant.
ile water to reduce the antibiotic effect on
the infant.
C.Move about every hour.
A 38-week primigravida who works as a
secretary and sits at a computer 8 hours
Rationale:
each day tells the nurse that her feet
Pooling of blood in the lower extremities
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
results from the enlarged uterus exert-
have begun to swell. Which instruction ing pressure on the pelvic veins. Moving
will aid in the prevention of pooling of about every hour will relieve pressure
blood in the lower extremities? on the pelvic veins and increase venous
return. Option A would increase venous
A.Wear support stockings. return from varicose veins in the lower
extremities but would be of little help with
B.Reduce salt in the diet. swelling. Option B might be helpful with
generalized edema but is not specific
C.Move about every hour. for edematous lower extremities. Option
D does not address venous return, and
D.Avoid constrictive clothing. there is no indication in the question that
constrictive clothing is a problem.
Twenty-four hours after admission to the
newborn nursery, a full-term male infant
develops localized swelling on the right
A.Cephalhematoma, which is caused by
side of his head. In a newborn, what is
forceps trauma
the most likely cause of this accumu-
lation of blood between the periosteum
Rationale: Cephalhematoma, a slight ab-
and skull that does not cross the suture
normal variation of the newborn, usually
line?
arises within the first 24 hours after de-
livery. Trauma from delivery causes cap-
A.Cephalhematoma, which is caused by
illary bleeding between the periosteum
forceps trauma
and skull. Option C is a cranial distortion
lasting 5 to 7 days, caused by pressure
B.Subarachnoid hematoma, which re-
on the cranium during vaginal delivery,
quires immediate drainage
and is a common variation of the new-
born. Options B and D both involve in-
C.Molding, which is caused by pressure
tracranial bleeding and could not be de-
during labor
tected by physical assessment alone.
D.Subdural hematoma, which can result
in lifelong damage
Prior to discharge, what instructions
should the nurse give to parents regard- C.Allow the cord to air-dry as much as
ing the newborn's umbilical cord care at possible.
home?
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
A.Wash the cord frequently with mild
soap and water.
Rationale:Recent studies have indicated
that air drying or plain water application
B.Cover the cord with a sterile dressing.
may be equal to or more effective than
alcohol in the cord healing process. Op-
C.Allow the cord to air-dry as much as
tions A, B, and D are incorrect because
possible.
they promote moisture and increase the
potential for infection.
D.Apply baby lotion after the baby's daily
bath
C.Place petroleum ointment around the
A mother expresses fear about chang-
glans with each diaper change and
ing the infant's diaper after circumcision.
cleansing.
What information should the nurse in-
clude in the teaching plan?
Rationale:
With each diaper change, the glans pe-
A.Cleanse the penis with prepackaged
nis should be washed with warm water to
diaper wipes every 3 to 4 hours.
remove any urine or feces, and petrole-
um ointment should be applied to prevent
B.Wash off the yellow exudate on the
the diaper from sticking to the healing
glans once every day to prevent infec-
surface. Prepackaged wipes often con-
tion.
tain other products that may irritate the
site. The yellow exudate, which covers
C.Place petroleum ointment around
the glans penis as the area heals and
the glans with each diaper change and
epithelializes, is not an infective process
cleansing.
and should not be removed. If bleeding
occurs at home, the client should be in-
D.Apply pressure by squeezing the pe-
structed to apply gentle pressure to the
nis with the fingers for 5 minutes if bleed-
site of the bleeding with sterile gauze
ing occurs.
squares and call the health care provider.
A 26-year-old gravida 2, para 1, client
is admitted to the hospital at 28 weeks
C.Tachycardia and a feeling of nervous-
of gestation in preterm labor. She is
ness
given three doses of terbutaline sulfate
(Brethine), 0.25 mg subcutaneously, to
Rationale: Terbutaline sulfate (Brethine),
stop her labor contractions. What are the
a beta-sympathomimetic drug, stimu-
primary side effects of terbutaline sul-
fate?
