HESI Maternity Practice Letitia_Gordon Q159

Question 1

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

a. Check the hematocrit results.
b. Administer pain medication.
c. Increase the rate of IV fluids.
d. Monitor client for contractions.

Answer 1

c. Increase the rate of IV fluids.

Question 2

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best?

a. a home pregnancy test can be used right after your first missed period
b. these tests are most accurate after you have missed your second period
c. home pregnancy tests often give false positives and should not be trusted
d. the test can provide accurate information when used right after ovulation

Answer 2

a. a home pregnancy test can be used right after your first missed period

Question 3

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is:

a. shortness of breath
b. joint pain
c. a persistent cold
d. organmegaly

Answer 3

c. a persistent cold

Question 4

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client’s blood pressure drops from 120/80 to 90/60. What action should the nurse take?

a. notify the healthcare provider or anesthesiologist
b. continue to assess the blood pressure q5min
c. place the woman in a lateral position
d. turn off continuous epidural

Answer 4

c. place the woman in a lateral position

Question 5

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant’s fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the

a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week
b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the week
c. anterior fontanel closes at 8 to 11 months and the posterior by the end of the second week
d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month

Answer 5

d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month

Question 6

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client’s care?

a. patellar reflex 4+
b. blood pressure 158/80
c. four hour urine output 240 ml
d. respiration 12/minute

Answer 6

a. patellar reflex 4+

Question 7

A 4 week old premature infant has been receiving epoetin alfa for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective?

a. slowly increasing urine output over the last week
b. respiratory rate changes from the 40s to the 60s
c. changes in apical heart rate from the 180 to the 140s
d. change in indirect bilirubin from 12 mg/dl to 8 mg/dl

Answer 7

c. changes in apical heart rate from the 180 to the 140s

Question 8

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nagele’s rule, what is the estimated date of delivery?

a. April 25, 2007
b. May 9, 2007
c. May 29, 2007
d. June 2, 2007

Answer 8

b. May 9, 2007

Question 9

The nurse is performing a AGA on a full-term newborn during the first hour of transition using the Dubowitz scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. Which findings should the nurse identify to determine if the neonate is SGA? (Select all that apply.)

a. admission weight of 4 lbs 15 oz
b. head to heel length of 17 in
c. frontal occipital circumference of 12.5 in
d. skin smooth with visible veins and abundant vernix
e. anterior plantar crease and smooth heel surfaces
f. full flexion of all extremities in resting supine position

Answer 9

a, b, c

Question 10

The nurse assess a client admitted to the labor and delivery unit and obtains the following data: BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

a. insert a fetal monitor
b. assess for cervical changes q1H
c. monitor bleeding from IV sites
d. perform Leopold’s maneuvers

Answer 10

c. monitor bleeding from IV sites

Question 11

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assess an apical heart rate of 80 bpm and respirations 20. What action should the nurse perform next?

a. initiate positive pressure ventilation
b. intervene after one minute APGAR is assessed
c. initiate CPR on the infant
d. assess the infant’s blood glucose level

Answer 11

a. initiate positive pressure ventilation

Question 12

A client with no prenatal care arrives at the labor unit screaming, “The baby is coming!” The nurse performs a vaginal examination that reveals the cervix is 3 cm dilated and 75% effaced. What additional information is most important for the nurse to obtain?

a. gravidity and parity
b. time and amount of last oral intake
c. date of last normal menstrual period
d. frequency and intensity of contractions

Answer 12

c. date of last normal menstrual period

Question 13

A mutigravida client at 41 weeks gestation present in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status?

a. biophysical profile
b. ultrasound for fetal abnormalities
c. maternal serum alpha-fetoprotein screening
d. percutaneous umbilical blood sampling

Answer 13

a. biophysical profile

Question 14

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?

a. raise the foot of the bed
b. assess for vaginal bleeding
c. evaluate the fetal heart rate
d. take the client’s blood pressure

Answer 14

a. raise the foot of the bed

Question 15

A client at 28 weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?

a. come to the clinic today for an ultrasound
b. go immediately to the emergency room
c. lie on your left side for about one hour and see if the bleeding stops
d. bring a urine specimen to the lab tomorrow to determine if you have a UTI

Answer 15

a. come to the clinic today for an ultrasound

Question 16

Which nursing intervention is helpful in relieving “afterpains”?

a. using relaxation breathing techniques
b. using a breast pump
c. massaging the abdomen
d. giving oxytocic medications

Answer 16

a. using relaxation breathing techniques

Question 17

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurses should know that ovulation usually occurs

a. two weeks before menstruation
b. immediately after menstruation
c. immediately before menstruation
d. three weeks before menstruation

Answer 17

a. two weeks before menstruation

Question 18

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurses’s response should be based on what information?

a. males inherit the disorder with a greater frequency than females
b. each pregnancy carries a 50% chance of inheriting the disorder
c. the disorder occurs in 25% of pregnancies
d. all children will be carriers of the disorder

Answer 18

b. each pregnancy carries a 50% chance of inheriting the disorder

Question 19

The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?

a. yellowish tinge to the skin
b. Babinski reflex present bilaterally
c. pink papular rash on the face
d. Moro reflex noted after a loud noise

Answer 19

a. yellowish tinge to the skin

Question 20

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client?

a. elevate lower legs while resting
b. increase caloric intake by 200 to 300 calories per day
c. increase water intake to 8 full glasses per day
d. take prescribed multivitamin and mineral supplements

Answer 20

d. take prescribed multivitamin and mineral supplements

Question 21

Which assessment finding should the nursery nurse report to the pediatric healthcare provider?

a. blood glucose level of 45
b. blood pressure of 82/45
c. non-bulging anterior fontanel
d. central cyanosis when crying

Answer 21

d. central cyanosis when crying

Question 22

A 28 year old client in active labor complains of cramps in her leg. What intervention should the nurse implement?

a. massage the calf and foot
b. extend the leg and dorsiflex the foot
c. lower the leg off the side of the bed
d. elevate the leg above the heart

Answer 22

b. extend the leg and dorsiflex the foot

Question 23

A new mother asks the nurse “How do I know that my daughter is getting enough breast milk?” Which explanation should the nurse provide?

a. weigh the baby daily and if she is gaining weight she is eating enough
b. your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day
c. offer the baby extra bottle milk after her feeding and see if she is still hungry
d. if you’re concerned you might consider bottle feeding so that you can monitor her intake

Answer 23

b. your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day

Question 24

On admission to the prenatal clinic, a 23 year old woman tells the nurse that her last menstrual period began on February 15 that previously her periods were regular. Her pregnancy test is positive. This client’s expected date of delivery

a. November 22
b. November 8
c. December 22
d. October 22

Answer 24

a. November 22

Question 25

An off-duty finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

a. provide as much privacy as possible for the woman
b. use a thread to tie off the umbilical cord
c. put the newborn to breast
d. reassure the husband and try to keep him calm

Answer 25

c. put the newborn to breast

Question 26

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have

a. a higher rate of congenital abnormalities
b. respiratory distress
c. lower birth weights
d. lower APGAR scores

Answer 26

c. lower birth weights

Question 27

A new mother who has just had her first baby says to the nurse, “I saw the baby in the recovery room. She sure has a funny looking head.” Which response by the nurse is best?

a. this is not an unusual shaped head especially for a first baby
b. that is normal the head will return to a round shape within 7 to 10 days
c. it may look funny to you but newborn babies are often born with heads like your baby’s
d. your pelvis was too small so the baby’s head had to adjust to the birth canal

Answer 27

b. that is normal the head will return to a round shape within 7 to 10 days

Question 28

After each feeding, a 3 day old newborn is spitting up large amounts of newborn formula, a nonfat cow’s milk formula. The pediatric healthcare provider changes the neonates’s formula to Similac. What information should the nurse provide to the mother about the newly prescribed formula?

a. Enfamil formula is demineralized whey formula that is needed with diarrhea
b. The new formula is a coconut milk formula used with babies with impaired fat absorption
c. the new formula is a casein protein source that is low in phenylalanine
d. Similac is a soy based formula that contains sucrose

Answer 28

d. Similac is a soy based formula that contains sucrose

Question 29

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse’s response is based on what knowledge?

a. iron absorption is decreased in the GI tract during pregnancy
b. it is difficult to consume 18 mg of additional iron by diet alone
c. iron is needed to prevent megaloblastic anemia in the last trimester
d. supplementary iron is more efficiently utilized during pregnancy

Answer 29

b. it is difficult to consume 18 mg of additional iron by diet alone

Question 30

When explaining postpartum blues to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (select all that apply)

a. panic attacks
b. tearfulness
c. decreased need for sleep
d. mood swings
e. disinterest in the infant

Answer 30

b. tearfulness
d. mood swings

Question 31

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?

a. recognize this is a common reaction in new mothers
b. ask the mother why she won’t look at the infant
c. observe the mother for other attachment behaviors
d. examine the newborn’s eyes for the ability to focus

Answer 31

c. observe the mother for other attachment behaviors

Question 32

A couple concerned because the woman has not been able to conceive is referred to a HCP for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent?

a. shoulder pain
b. leg cramps
c. back pain
d. abdominal pain