HESI RN Maternity Exam
VERSION 5
Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?
Have the client empty her bladder. Correct
Request the client lie on her left side.
Perform Leopold’s maneuvers first.
Give the client some cold juice to drink.
To accurately measure the fundal height, the bladder must be empty (A) to avoid elevation of the uterus.Fundal height is not measured with the client lying on her side (B). Leopold's maneuvers are performed to assess fetal position and the expected location of the point of maximal impulse (PMI) for fetal heart rate (C). Cold juice (D) does not affect the fundal height measurement, but may be given to arouse the fetus if the fetus appears to be sleeping during a non-stress test.
Awarded 1.0 points out of 1.0 possible points.
2.ID: 311028927
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
Elicit a positive scarf sign on the affected side.
Observe for an asymmetrical Moro (startle) reflex. Correct
Watch for swelling of fingers on the affected side.
Note paralysis of affected extremity and muscles.
The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the 1 / 4
affected arm, malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved. Eliciting (A) (extending arm across the chest toward the opposite shoulder) is contraindicated if a fractured clavicle is present. (C and D) on the affected side require follow-up, but are not indicative of a fractured clavicle.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 310955049
One hour after giving birth to an 8-pound infant, a client’s lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately?
Give the medication as prescribed and monitor for efficacy.
Encourage the client to breastfeed rather than bottle feed.
Have the client empty her bladder and massage the fundus.
Call the healthcare provider to question the prescription. Correct
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription (D). (A) compromises patient safety. While (B) releases endogenous oxytocin, and (C) promotes uterine contraction, questioning the administration of Methergine is a higher priority because it concerns medication safety.
Awarded 1.0 points out of 1.0 possible points.
4.ID: 311013689
The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?
A gravida 6, para 5 who is 38 years of age and in early labor.
A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station.
A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor
due to post dates.
A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.
Correct 2 / 4
When the presenting part is ballottable (D), it is floating out of the pelvis. In such a situation, the cord can descend before the fetus causing a prolapsed cord, which is an emergency situation. (A, B, and C) do not present problems with administration of an enema.
Awarded 1.0 points out of 1.0 possible points.
5.ID: 310945203
In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse assign to this infant?(Enter numeral value only.)
Correct
Awarded 1.0 out of 1.0 possible points.
6.ID: 310951930
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client?
Which symptom did you experience first?
Are you eating large amounts of salty foods?
Have you visited a foreign country recently?
Do you have a history of rheumatic fever? Correct
Clients with a history of rheumatic fever (D) may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client's health history is a priority. (A) is not important. Salty foods (B) sometimes cause edema, but this client is experiencing additional cardiac symptoms. (C) assesses for possible exposure to microorganisms, but these symptoms are more indicative of a cardiovascular etiology.
Awarded 1.0 points out of 1.0 possible points.
7.ID: 310974981
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take?
4 3 / 4
Check the client for urinary bladder distention.
Notify the healthcare provider of the nonreactive results.
Have the mother stimulate the fetus to move.
Ask the client if she has felt any fetal movement. Correct
The client should be asked if she has felt the fetus move (D). An NST is used to determine fetal well- being, and is often implemented when postmaturity is suspected. A "reactive" NST occurs if the FHR accelerates 15 bpm for 15 seconds in response to the fetus' own movement, and is "nonreactive" if no FHR acceleration occurs in response to fetal movement. The client should empty her bladder before starting the test, but bladder distention does not impede fetal movement (A). The client should be quizzed about fetal movement before determining that the NST is nonreactive (B). If no movement has occurred in the last 20 to 30 minutes, it is likely that the fetus is sleeping--providing the mother with orange juice often wakes the infant, and then the NST should be conducted again.
Awarded 1.0 points out of 1.0 possible points.
8.ID: 310955099
A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?
Patellar reflex 4+. Correct
Blood pressure 158/80.
Four-hour urine output 240 ml.
Respiration 12/minute.
A 4+ reflex in a client with pregnancy-induced hypertension (A) indicates hyperreflexia, which is an indication of an impending seizure. Although (B) is significant, some individuals have preeclampsia superimposed on chronic hypertension, and an elevated blood pressure alone is not as significant a finding as (A). (C and D) are important, but these findings are within normal range.
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