OB/Peds Hesi Flashcards
When is the screening test for PKU done?
At 2-3 days of life, or after enough breast or formula (usually after 24 hours) is ingested to allow for determination of body’s ability to metabolize amino acid phenylalanine.
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child?
Foods sweetened with aspartame
During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. What action should the nurse implement?
Inform her that this is a normal physiological change.
A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?
Take your blood pressure now and if it is seriously elevated, go to the hospital.
What is the difference between caput succedaneum and cephalhematoma?
Cephalhematoma does NOT cross suture lines and manifests a few hours after birth
A new mother asks the nurse about an area of swelling on her baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?
“This is called caput succedaneum. It will absorb and cause no problems.”
Patient with continuous fetal monitoring notices FHR fall and rise abruptly with “v” shaped pattern. Nurse action to take first?
change position of patient
When planning care for a laboring client , the nurse identifies the need to withhold solid foods while the client is in labor . What is the most important reason for this nursing intervention ?
An increased risk for aspiration can occur if general analgesic is needed
Which physiological parameter is most important for the nurse to monitor during administration of oxytocin (Pitocin)?
fetal heart rate
A multiparous woman at 38 weeks gestation with a history of rapid progression of labor is admitted for induction due to signs and symptoms of pregnancy induced hypertension (PIH). One hour after the oxytocin infusion is initiated she complains of a headache. Her contractions are occurring every 1-2 mins , lasting 60-75 seconds and a vaginal exam reveals that her cervix is 90% and dilated 6 cm.What intervention is most important for the nurse to implement?
Discontinue the Pitocin infusion
A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
Contraction pattern.
A 38-week primigravida is admitted to labor and delivery after a non-reactive stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin) infusion. Which finding is most important for the nurse to report to the healthcare provider?
pattern of fetal late decelerations.
A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide?
Apply hot packs just before each feeding.
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?
Encourage the mother to stop feeding for a few minutes and comfort the infant.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?
Apply cold compresses to both breasts for comfort
The client is experiencing engorgement even though she is bottle-feeding her infant, and cold compresses
may help reduce discomfort.
The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?
Observe the mother for other attachment behaviors.
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn’s…
Heat loss
Upon admission to the nursery, the nurse places a newborn supine under radiant warmer , an external heat source. What should the nurse implement first to ensure safe thermoregulation?
Place temperature probe on the abdomen in the line with the radiant heat source
The nurses assessment on a preterm infant reveals decreased muscle tone , sign of respiratory distress , irritability , mottled cool skin.Which intervention should the nurse implement first ?
Position a radiant warmer on the crib
A new mother asks the nurse why her infant son has a needle mark on his leg. Which response is best for the nurse to provide the mother?
Your baby was given an injection of vitamin K to prevent bleeding
The parents of a male newborn have signed an informed consent for circumcision. What priority intervention should the nurse implement upon completion of the circumcision?
Place petroleum gauze dressing on the site.
A mother expresses fear about changing the infant’s diaper after circumcision. What information should the nurse include in the teaching plan?
Place petroleum ointment around the glans with each diaper change and cleansing.
A client breastfeeding her child reports a painful swollen breast with cracked and sore nipple on the right side. What should the nurse instruct the client?
feed the child every 2 to 4 hours and empty each breast completely
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?
Breastfeed the infant, ensuring that both breasts are completely emptied.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?
Ensure that the baby is positioned correctly for latching on.
The nurse should be aware that which condition is a contraindication to inducing labor
Placenta previa.
A patient who is 32 weeks gestation has the following symptoms: dark, red vaginal bleeding, 100 bpm FHR, rigid abdomen and severe pain. What is the difference between abruptio placentae and placenta previa?
Placenta previa: painless bright red bleeding occurring in the third trimester
A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply.)
a. Dark, red vaginal bleeding.
b. Increased uterine irritability.
c. A rigid abdomen.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
Monitor bleeding from IV sites. Monitoring bleeding from peripheral sites is the priority intervention. This client is presenting with signs of placental abruption
Patient presents with bright red blood, rigid abdomen and in pain. Nurse suspects possibility?
abruptio placentae
The nurse notes a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?
Elevate the presenting part off the cord.
The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.)
A. Avoids eye contact.
B. Interacts with a flat affect.
C. Reports feeling sad.
D. Expresses suicidal thoughts
A 2-day-old full-term infant is brought to the neonatal ICU for treatment of early onset sepsis. Which is the most likely infecting organism in this client?
Group B Strep
The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and been walking without assistance for one month. Which technique should the nurse select for administration?
Administer the injection into the middle of the lateral aspect of the thigh.
The nurse is administering an oral medication to a reluctant preschool-age boy. Which
intervention should the nurse implement?
Use straightforward approach with the child
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?
reassure the mother that the infant is old enough to eat iron-fortified cereal
While auscultating the lung sounds of a 5 year old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. What action is best for the nurse to take?
Inquire about the use of alternative methods of treatment.
(Cupping is popular form of tx in Asian cultures)
The nurse is caring for a female client with scoliosis who had a posterior spinal fusion and is in a body jacked cast. Which assessment finding indicates to the nurse the client is developing cast syndrome?
Abdominal distention.
Nurse screening only the highest risk children for scoliosis?
Girls between ages 10 and 14
An adolescent boy is hospitalized with full-thickness (third degreed) burns to both hands following a house fire. Three days after his admission to the burned unit, the nurse notes that teenager’s hands are becoming more edematous. Which intervention is most important for the nurse to include in this client’s plan care?
Assess radial pulses every 2 hours
Upon inspection, a nurse visualizes a blade of grass clipping stuck under the right upper eyelid of a teenage client complaining of eye pain, increased tear production, and redden sclera. What should the nurse use to remove the grass clipping?
Moist gauze pad.
During a routine well-child exam, the nurse observes that a 12-month-old child is unable to pronounce any simple words or syllables. Which possible cause should the child be evaluated for first?
Hearing loss.
In caring for an client with acute epiglottitis, which nursing action takes priority?
Prepare for endotracheal intubation
During a follow up clinical visit a mother tells the nurse that her 5 month old son who had surgical correction for tetralogy of Fallot has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?
Auscultate heart and lungs while infant is held
