HESI RN Maternity Exam

HESI RN Maternity Exam

VERSION 9

• 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?

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.

Points Earned:1/1

Correct Answer:D

Your Response:D

• A client at 28-weeks gestation calls the antepartal clinic

and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?

• Come to the clinic today for an ultrasound.
• Go immediately to the emergency room.
• Lie on your left side for about one hour and see if the bleeding stops.
• Bring a urine specimen to the lab tomorrow to determine if you have a

urinary tract infection.Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life- threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound (A). Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which IS life-threatening to the mother and fetus--then (B) would be appropriate. (C) does not take the symptoms seriously. The woman is not describing symptoms of a UTI (D).

Points Earned:1/1

Correct Answer:A

Your Response:A

• A primigravida at 40-weeks gestation is receiving oxytocin

(Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin?

• Dehydration.
• Hyperstimulation.
• Galactorrhea.
• Fetal tachycardia.

Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture, and fetal distress or demise. Dehydration (A) and galactorrhea (C) are not adverse effects associated with the administration of Pitocin.Fetal tachycardia (D) is an initial response to any stressor, including an increase in 1 / 3

maternal temperature or intrauterine infection, but fetal decelerations indicate distress following tetanic contractions.

Points Earned:1/1

Correct Answer:B

Your Response:B

• When explaining "postpartum blues" to a client who is 1

day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.)

• Mood swings.
• Panic attacks.
• Tearfulness.
• Decreased need for sleep.
• Disinterest in the infant.

Correct choices are (A and C). "Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after delivery and include mood swings (A), tearfulness (C), feeling low, emotional, and fatigued. (B, D, and E) are more characteristic of postpartum depression that typically occurs 3 to 7 days later than postpartum blues.

Points Earned:1/2

Correct Answer:A, C

Your Response:A, C, E

• The nurse is assessing the umbilical cord of a newborn.

Which finding constitutes a normal finding?

A. Two vessels: one artery and one vein.

B. Two vessels: two arteries and no veins.

C. Three vessels: two arteries and one vein.

D. Three vessels: two veins and one artery.

The normal umbilical cord contains three vessels--two arteries and one vein (C). Fewer than three vessels correlates with various congenital anomalies, such as cardiac and renal anomalies. (A, B, and D) would constitute abnormal findings.

Points Earned:0/1

Correct Answer:C

Your Response:D

• At 14-weeks gestation, a client arrives at the Emergency

Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

• Check the hematocrit results.
• Administer pain medication.
• Increase the rate of IV fluids.
• Monitor client for contractions.

The client is demonstrating symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at approximately 14-weeks gestation when embryonic growth expands the fallopian tube causing its rupture, and can result in hemorrage and hypovolemic shock. Increasing the IV infusion rate (C) provides intravascular fluid to maintain blood pressure. (A, B, and D) can be implemented after fluid replacement is increased.

Points Earned:1/1

Correct Answer:C 2 / 3

Your Response:C

• A new mother who has just had her first baby says to the

nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best?

• This is not an unusual shaped head, especially for a first baby.
• It may look funny to you, but newborn babies are often born with head

your baby's.

• That is normal; the head will return to a round shape within 7 to 10 da
• Your pelvis was too small, so the baby's head had to adjust to the birth

(C) reassures the mother that this is normal in the newborn and provides correct information regarding the return to a "normal" shape. Although (A) is correct, it implies that the client should "not worry." Any implied or spoken "don't worry" is usually the wrong answer! (B) is condescending and dismissing--the mother is seeking reassurance and information. (D) is a negative statement and implies that molding is the mother's "fault."

Points Earned:1/1

Correct Answer:C

Your Response:C

• A 35-year-old primigravida client with severe preeclampsia

is receiving magnesium sulfate via continuous IV infusion.Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?

• Deep tendon reflexes 2+.
• Blood pressure 140/90.
• Respiratory rate 18/minute.
• Urine output 90 ml/4 hours.

Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity. (A, B, and C) do not indicate a magnesium sulfate toxicity.

Points Earned:1/1

Correct Answer:D

Your Response:D

• Twenty minutes after a continuous epidural anesthetic is

administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take?

• Notify the healthcare provider or anesthesiologist immediately.
• Continue to assess the blood pressure q5 minutes.
• Place the woman in a lateral position.
• Turn off the continuous epidural.

The nurse should immediately turn the woman to a lateral position (C), place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it further decreases, the anesthesiologist/healthcare provider should be notified immediately (A). Continued assessment of (B), without taking any further action would constitute malpractice. (D) may also be warranted, but such action is based on hospital protocol.

Points Earned:1/1

Correct Answer:C

Your Response:C

• The nurse is teaching breastfeeding to prospective parents

in a childbirth education class. Which instruction should the nurse include as content in the class?

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