HESI PN MATERNITY PROCTORED EXAM
VERSION 5
- A nurse in the labor and delivery unit receives a phone call from a client who reports that her
- Braxton hick's contractions
- Rupture of membranes
- Fetal descent
- True contractions
contractions started about 2 hr. ago, did not go away when she had two glasses of water and rested, and became stronger since she started walking. Her contractions occur every 10 min and last about 30 seconds. She hasn't had a fluid leak form her vagina. However, she saw some blood when she wiped after voiding. Based on this report, which of the following clinical findings should the nurse recognize that the client is experiencing
D - true contractions
- A nurse in the labor and delivery unit is caring for a client in labor and applies an external
- min and 30 to 40 seconds in duration. The nurse performs a vaginal exam and finds the cervix
- First stage, latent phase
- First stage, active phase
- First stage, transition phase
- Second stage of labor
fetal monitor and tocotransducer. The FHR is around 140/min. contractions are occurring every
is 2 cm dilated, 50% effaced, and the fetus is at a -2 station. Which of the following stages and phases of labor is the client experiencing
A - first stage, latent phase
- A client experiences a large gush of fluid from her vagina while walking in the hallway of the
- Check the amniotic fluid for meconium
- Monitor FHR for distress
- Dry the client and make her comfortable
- Monitor uterine contractions
birthing unit. Which of the following actions should the nurse take first?
B - monitor the fetal hear rate for distress
- A nurse in labor and delivery unit is completing an admission assessment for a client who is
- Cord prolapse
- Infection
- Postpartum hemorrhage
- Hydramnios
at 39 weeks of gestation. The client reports that she has been leaking fluid from her vagina for 2 days. Which of the following conditions is the client at risk for developing
B - infection
- A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The
client is very irritable and feels the urge to have a bowel movement. She states, "I've had enough. I can't do this anymore. I want to go home right now" which stage of labor is the client 1 / 2
experiencing?
- Second stage
- Fourth state
- Transition phase
- Latent phase
C - transition phase
- A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions
- Encourage the use of patterned breathing techniques
- Insert an indwelling urinary catheter
- Administer opioid analgesic medication
- Suggest application of cold
- Provide ice chips
every 3 to 5 minutes and becoming stronger. A vaginal exam reveals that the clients cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? (select all that apply)
A - encourage the use of patterned breathing techniques C - administer opioid analgesic medication D - suggest application of cold
- A nurse is caring for a client who is in active labor. The client reports lower back pain. The
- An abdominal effleurage
- Sacral counterpressure
- Showering if not contraindicated
- Back rub and massage
nurse suspects this pain is related to a persistent occiput posterior fetal position which of the following nonpharm nursing interventions should the nurse recommend to the client?
B - sacral counterpressure
- A nurse is caring for a client following the administration of an epidural block and is preparing
- It is needed to promote increased urine output
- It is needed to counteract respiratory depression
- It is needed to counteract hypotension
- It is needed to prevent oligohydramnios
to administer an IV fluid bolus. The clients partner asks about the purpose of the IV fluids.Which of the following is an appropriate response for the nurse to make?
C - it is needed to counteract hypotension
- A nurse is caring for a client who is in the second stage of labor. The clients labor has been
- Pudendal
- Epidural
- Spinal
- Paracervical
- / 2
progressing, and she is expected to deliver vaginally in 20 min. the provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered?
A - pudendal