HESI RN Maternity Exam

HESI RN Maternity Exam

VERSION 18

• A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV

piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? mL.

• A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36

weeks' gestation. The assessments during this visit include BP 140/90, P 80, and +2 edema of the ankles and feet. What further information should the nurse obtain to determine if this client is becoming preeclamptic?

• Headaches.
• Blood glucose level.
• Proteinuria.
• Edema in lower extremities.
• The nurse is instructing a preeclamptic client about monitoring the movements of

her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concerning fetal movement?

• “If the fetus is becoming less active than before.”
• “If it takes longer each day for the fetus to move 10 times.”
• “If the fetus stops moving for 12 hours.”
• “If the fetus moves more often than 3 times an hour.”
• A 29-year-old multigravida at 37 weeks' gestation is being treated for severe

preeclampsia and has magnesium sulfate infusing at 3 g/h. To maintain safety for this

client, the priority intervention is to:

• Maintain continuous fetal monitoring.
• Encourage family members to remain at bedside.
• Assess reflexes, clonus, visual disturbances, and headache.
• Monitor maternal liver studies every 4 hours. 1 / 4

• At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches

(151.7 cm) has gained a total of 20 lb (9.1 kg), with a 1-lb (0.45-kg) gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia?

• Total weight gain.
• Short stature.
• Adolescent age group.
• Proteinuria.
• After instructing a primigravid client at 38 weeks' gestation about how

preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following?

• Hydrocephalic infant.
• Abruptio placentae.
• Intrauterine growth retardation.
• Poor placental perfusion.
• After instructing a multigravid client diagnosed with mild preeclampsia how to

keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effective when the client says that she will count the number of times the baby moves during which of the following time spans?

• 30-minute period three times a day.
• 45-minute period after lunch each day.
• 1-hour period each day.
• 12-hour period each week.
• When teaching a multigravid client diagnosed with mild preeclampsia about

nutritional needs, which of the following types of diet should the nurse discuss?

• High-residue diet.
• Low-sodium diet. 2 / 4

• Regular diet.
• High-protein diet.
• A 17-year-old client at 33 weeks' gestation diagnosed with mild preeclampsia is

treated as an outpatient. The nurse instructs the client to contact the health care provider immediately if she experiences which of the following?

• Blurred vision.
• Ankle edema.
• Increased energy levels.
• Mild backache.
• A primigravid client at 38 weeks' gestation diagnosed with mild preeclampsia

calls the clinic nurse to say she has a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. The nurse should tell

the client:

• “Take two acetaminophen (Tylenol) tablets. They aren't as likely to upset your

stomach.”

• “I think the doctor should see you today. Can you come to the clinic this

morning?”

• “You need to lie down and rest. Have you tried placing a cool compress over

your head?”

• “I'll ask the doctor to call in a prescription for aspirin with codeine. What's your

pharmacy's number?”

• When preparing the room for admission of a multigravid client at 36 weeks'

gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain?

• Oxytocin infusion solution.
• Disposable tongue blades.
• Portable ultrasound machine.
• Padding for the side rails.
• The primary health care provider prescribes intravenous magnesium sulfate for 3 / 4

a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside?

• Diazepam (Valium).
• Hydralazine (Apresoline).
• Calcium gluconate.
• Phenytoin (Dilantin).
• For the client who is receiving intravenous magnesium sulfate for severe

preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia?

• Decreased deep tendon reflexes.
• Cool skin temperature.
• Rapid pulse rate.
• Tingling in the toes.
• A client at 28 weeks' gestation presents to the emergency department with a

“splitting headache.” What actions are indicated by the nurse at this time? Select all that apply.

• Reassure the client that headaches are a normal part of pregnancy.
• Assess the client for vision changes or epigastric pain.
• Obtain a nonstress test.
• Assess the client's reflexes and presence of clonus.
• Determine if the client has a documented ultrasound for this pregnancy.
• Which of the following would the nurse identify as the priority to achieve when

developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?

• Decreased generalized edema within 8 hours.
• Decreased urinary output during the first 24 hours.
• Sedation and decreased reflex excitability within 48 hours.
• Absence of any seizure activity during the first 48 hours.
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