HESI Flashcards
1. A postpartum patient was in labor for 30 hours and had ruptured members for 24 hours. For which of the following would the nurse be alert? A. Endometritis B. Endometriosis C. Salpingitis D. Pelvic Thrombophlebitis
A. Explanation: endometritis is an infection of the uterine lining and can occur after a prolonged rupture of membranes. endometriosis does not occur after strong labor and prolonged rupture of membranes. salpingitis is a tubal infection and could occur if endometritis is not treated. pelvic thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of membranes.
- A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction?
A. The ultrasound will help to locate the placenta
B. The ultrasound identifies blood flow through the umbilical cord
C. The test will determine where to insert the needle
D. The ultrasound locates a pool of amniotic fluid.
B. Explanation: before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.
3. While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy? A. Calcium gluconate B. Protamine sulfate C. Methylergonvovine (Methergine) D. Nitrofurantoin (macrodantin)
B. Explanation: protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose
When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?
A. Turn the neonate every 6 hours
B. Encourage the mother to discontinue breastfeeding
C. Notify the physician if the skin becomes bronze in color
D. Check the vital signs every 2 to 4 hours
D. Explanation: while caring for an infant receiving phototherapy for the treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.
A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? A. back B. abdomen C. fundus D. perineum
D. Explanation: a bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.
The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:
A. “ Nausea and vomiting can be decreased if I eat a few crackers before arising”.
B. “If I start to leak colostrum, I should cleanse my nipples with soap and water.”
C. “If I have a vaginal discharge, I should wear nylon underwear”
D. “Leg cramps can be alleviated if I put an ice pack on the area”
A. Explanation: Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.
Forty-eight hours after delivery, the nurse in charge plans discharges teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following? A. Taking in B. Letting go C. Taking hold D. Resolution
C. Explanation: beginning after completion of the taking in phase, the taking hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills.
A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following: A. Activity limited to bed rest B. Platelet infusion C. Immediate cesarean delivery D. Labor induction with oxytocin
A. Explanation: Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client’s bleeding.
The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?
A. Feeding the neonate a maximum of 5 minutes per side on the first day
B. Wearing a supportive brassiere with nipple shields
C. Breastfeeding the neonate at frequent intervals
D. Decreasing fluid intake for the first 24 to 48 hours
C. Explanation: Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate’s and mother’s needs.
When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened and begins to cry. The nurse interprets these reactions as indicative of which of the following reflexes? A. Startle reflex B. Babinski reflex C. Grasping reflex D. Tonic neck reflex
A. Explanation: The Moro, or startle reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex present at birth disappears at about age 3 months.
A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform: A. Tailor sitting B. Leg lifting C. Shoulder circling D. Squatting exercises
A. Explanation: Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.
Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?
A. Notify the neonate’s pediatrician immediately
B. Check the diaper and circumcision again in 30 minutes
C. Secure the diaper tightly to apply pressure on the site.
D. Apply gentle pressure to the site with a sterile gauze pad.
D. Explanation: If bleeding occurs after the circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.
Which of the following would the nurse most likely expect to find when assessing a pregnant client with an abruption placenta? A. Excessive vaginal bleeding B. Rigid, board-like abdomen C. Titanic uterine contractions D. Premature rupture of membranes
B. Explanation: The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common.
While the client is in active labor with twins and the cervix is 5cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minutes period. Which of the following would be the nurse’s most appropriate action?
A. Note the fetal heart rate patterns
B. Notify the physician immediately
C. Administer oxygen at 6 liters by mask
D. Have the client pant-blow during the contraction
B. Explanation: The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contraction. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.
A client tells the nurse, “I think my baby likes to hear me talk to him.” When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response?
A. High-pitched speech with tonal variations
B. Low-pitched speech with a sameness of tone
C. Cooing sounds rather than words
D. Repeated stimulation with loud sounds
A. Explanation: Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sounds louder than about 55 decibels.
A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8cm, completely effaced (100%), and at 0 station. What phase of labor is she in? A. Active phase B. Latent phase C. Expulsive phase D. Transitional phase
D. Explanation: The transitional phase of labor extends from 8 to 10 cem; it is the shortest by most difficult and intense for the patient. The latent phase extends from 0 to 3cm; it is mild in nature. The active phase extends from 4 to 7cm; it is moderate for the patient. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.
A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond?
A. Yes, it produces no adverse effect
B. No, it can initiate premature uterine contractions
C. No, it can promote sodium retention
D. No, it can lead to increased absorption of fat-soluble vitamins
B. Explanation: Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils are not known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased
A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this patient? A. Knowledge deficit B. Fluid volume deficit C. Anticipatory grieving D. Pain
B. Explanation: If bleeding and clots are excessive, this patient may become hypovolemic. Pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.
Immediately after delivery, the nurse-midwife assesses the neonate’s head for signs of molding. Which factors determine the type of molding?
A. Fetal body flexion or extension
B. Materbak age body frame, and weight
C. Maternal and paternal ethnic backgrounds
D. Maternal parity and gravidity
A. Explanation: Fetal attitude - the overall degree of body flexion or extension- determines the type of molding in the head of a neonate. Molding is not influenced by maternal age, body frame, weight, parity, and gravidity or by maternal and paternal ethnic backgrounds.
For the patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? A. The membranes must rupture B. The fetus must be at 0 station C. The cervix must be dilated fully D. The patient must receive anesthesia
A. Explanation: Internal EFM can be applied only after the patient’s membranes have ruptured when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. although the patient may receive anesthesia, it is not required before application of an internal EFM device.
A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in the early part of the first stage of labor. Her pain is likely to be most intense:
A. Around the pelvic girdle
B. Around the pelvic girdle and in the upper arms
C. Around the pelvic girdle and at the perineum
D. At the perineum
A. Explanation: During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, the pain spreads to the upper legs and the perineum. During the late part of the second stage and during childbirth, intense pain occurs at the perineum. Upper arm pain is not common during any stage of the labor.
A female adult patient is taking a progestin-only oral contraceptive or mini pill. Progestin use may increase the patient's risk for: A. Endometriosis B. Female hypogonadism C. Premenstrual syndrome D. Tubal or ectopic pregnancy
D. Explanation: Women taking the minipill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis, female hypogonadism, and premenstrual syndrome are not associated with progestin-only oral contraceptives.
A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms?
A. Proteinuria, headaches, vaginal bleeding
B. Headaches, double vision, vaginal bleeding
C. Proteinuria, headaches, double vision
D. Proteinuria, double vision, uterine contractions
C. Explanation: A patient with pregnancy-induced hypertension complains of headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions are not associated with pregnancy-induced hypertension.
Because cervical effacement and dilation are not progressing in a patient in labor, the doctor orders IV administration of oxytocin (Pitocin). Why must the nurse monitor the patient's fluid intake and output closely during oxytocin administration? A. Oxytocin causes water intoxication B. Oxytocin causes excessive thirst C. Oxytocin is toxic to the kidneys D. Oxytocin has a diuretic effect
A. Explanation: The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe eater intoxication, leading to seizures, coma, death. Excessive thirst results from the work of labor and limited oral fluid intake-not oxytocin. Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.
Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? A. Low room humidity B. Cold weight scale C. Cools incubator walls D. Cool room temperature
C. Explanation: Common source of radiant hear loss includes cool incubator walls and windows. Low room humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to convective heat loss.
After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur? A. Decreased peristalsis B. Increase heart rate C. Dry mucous membranes D. Nausea and Vomiting
D. Explanation: Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase.
The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? A. Active phase B. Complete phase C. Latent Phase D. Transitional Phase
D. Explanation: The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1.5 to 2 minutes and last 45 to 90 seconds. The active phase lasts 4.5 to 6 hours; it is characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.
After 3 days of breastfeeding, a postpartum patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she:
A. Apple warm compresses to her nipples just before feeding.
B. Lubricate her nipples with expressed milk before feeding
C. Dry her nipples with a soft towel after feedings
D. Apply soap directly to her nipples and then rinse.
B. Explanation: Measures that help relieve nipple soreness in a breastfeeding patient include lubrication of the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.
The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? A. Between 10 to 12 weeks' gestation B. Between 16 to 20 weeks' gestation C. Between 21 to 23 weeks' gestation D. Between 24 to 26 weeks' gestation
B. Explanation: A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks’ gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.
Normal lochial findings in the first 24 hours postpartum include: A. Bright red blood B. Large clots or tissue fragments. C. A foul odor D. The complete absence of lochia
A. Explanation: Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.
Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first? A. Do you have any chronic illnesses? B. Do you have any allergies? C. What is your expected due date? D. Who will be with you during labor?
C. Explanation: When obtaining the history of a patient who may be in labor, the nurse’s highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complcations. Later, the nurse should ask about chronic illness, allergies, and support person.
