HESI PN MATERNAL NEWBORN PROCTORED EXAM

HESI PN MATERNAL NEWBORN PROCTORED EXAM

VERSION 19

• normal assessment finding of full-term newborn 1 hr after vaginal delivery: HEAD

CIRCUMFERENCE IS GREATER THAN THE CHEST CIRCUMFERENCE

p.268ati

2. look over SIDS: need for additional teaching

• which answer choice indicates that a new mother is having difficulty adjusting to

her role as a new mother

• for a female who is bottle-feeding her newborn, what should the nurse do if the

female's breast are warm & firm (I chose to teach the client to apply cold compresses). since the pt is bottle-feeding, there is no need to pump the breast because pumping will stimulate more milk to be made. The client with warm and firm breasts have breast engorgement...cold compresses are used for breast engorgement. Pg 223ati

• which statement by the client in post-term labor should the nurse give the highest

priority? (a) i have not felt my baby move as much today (b) i feel like i cannot breathe when i walk up the stairs (c) i saw a blood-streaked discharge a few hours ago (d) when my water broke, it was not clear my guess b/c amniotic fluid should be clear pg.185ati

• assessment finding for placenta previa (painless vaginal bleeding) pg. 71ati
• a client who is pregnant w/ twins is undergoing an amniocentesis. the nurse

knows that the client's elevated level of alpha fetoprotein most likely indicates:(a) a multifetal pregnancy (b) overestimation of gestation calculation (c) Rh incompatibility (d) fetal lung maturity pg.689text

8. highest priority for an adolescent who comes to the prenatal clinic: (a)

socioeconomic status (b) psychological readiness (c) partner support (d) nutritional status (my guess)

• A client is having back labor but is uncomfortable and wants a natural delivery;

nursing intervention: ( i think i chose to assist the client to a hands-and-knees position); one of the other choices was offer a whirlpool bath SACRAL

COUNTERPRESSURE HEAT/COLD THERAPY,

HYDROTHERAPY(WHIRLPOOL),ACUPRESSURE pg.133ati

• 13 weeks pregnant w/ hyperemesis gravidarum (vomiting/morning sickness).

which assessment finding concerns the nurse (KETONURIA//KETONES OF 2+) pg.94 ati, 704 text

• AA client who is at 40 weeks of gestation is admitted to the labor and delivery

unit with her cervix dilated 1 cm and 50% effaced(thinning of the cervix). Two hours 1 / 2

after receiving secobarbital (Seconal) 200 mg PO, the client wakes up and delivery is imminent. which of the following actions should the nurse take first?(1) place a bulb syringe in the radiant warmer (2) have naloxone (narcan) available for the newborn (3)obtain warm blankets to place around the newborn (4) test the function of the bag-valve mask pg. 159ati

• which choice should the nurse instruct the client to contact the primary care

provider (the nurse is providing discharge teaching): THE INFANT HAS LESS

THAN 6 WET DIAPERS IN 24 HOURS pg.309ati

• initial physical assessment on a newborn; which answer choice requires further

evaluation by the nurse: (1)bluish coloring of the feet (2)small, pin-pointed,

reddish-blue spots on the chest (3)gray-white cheesy substance covering the skin (4)overlapping suture lines (overlapping suture lines is a normal finding due to the molding of the head as the infant goes through the birth canal.acrocyanosis is also a normal finding. vernix is a normal finding) pg.270ati

• select all that apply: which assessment findings indicates that a newborn is

experiencing HYPOglycemia: jitterness, poor feeding, weak shrill cry, irregular

respirations, cyanosis, apnea, lethargy, diaphoresis,flaccid muscle tone, seizures/coma, glucose <40 pg. 318ati

• what should the nurse instruct a client who is 34 weeks to report immediately

(urinary frequency; ankle edema; persistent headache; increased leukorrhea)pg. 354text

• KNOW GTPAL pg.25ati
• nonpharmacological pain management for the client who had an episiotomy in

the 4th stage of labor (look over ice packs and warm sitz baths) others include squeeze bottle, topical anesthetic cream/spray, side lying pg.492, 495text

• for a client receiving oxytocin (pitocin), the fetal monitor shows a series of late

decelerations. Which action should the nurse take first: (1) stop the oxytocin

infusion (2) notify provider (3) position pt on her left side (4) administer oxygen via face mask pg.149ati

• which client should be assessed 1st...(I chose the client who had the burning w/

frequent urination for 5 days...the other choices indicated normal pregnancy findings. This one indicates that the pt has a UTI)

• preeclampsia...which finding requires intervention (1) Hgb of 14.8 (2) platelet

count 60,000 (3) serum creatinine 0.8 (4) urine protein concentration 200mg/24 hour  platelet count should be 150,000-450,000….Proteinuria is defined as a concentration at or greater than 300mg/24hr pg. 661text, 100ati

• One hour after delivery, a client who is receiving IV oxytocin (Pitocin) starts

passing moderate-sized clots. Vital signs reveal an increase in pulse rate and a decrease in blood pressure. after massaging the fundus, the nurse should first (1) give lactated ringer's IV bolus (2) administer methlergonovine (Methergine) (3)assist the client to a side-lying position (4)insert an indwelling urinary catheterThe findings indicate that the client is going into shock from losing too much blood...management of shock includes administration of IV fluids to replace what is lost] pg.237ati

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