Latest 2022 - 2023 HESI Maternity TEST BANK Questions and Answers Included - Passed - A+ Rated Guide
- Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?"
- Lying prone with a pillow on the abdomen
- Using a breast pump
- Massaging the abdomen
- Giving oxytocic medications
Lying prone (A) keeps the fundus contracted and is especially useful with multiparas, who commonly experience afterpains due to lack of uterine tone.
- A multigravida client arrives at the labor and delivery unit and tells the nurse that her
bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?
- Complete a sterile vaginal exam
- Take maternal temperature every 2 hours
- Prepare for an immediate cesarean birth
- Obtain sterile suction equipment
A vaginal exam (A) should be performed after the rupture of membranes to determine the presence of a prolapsed cord.
- 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
"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.
- A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted
for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
- Provide oral hydration
- Have a complete blood count (CBC) drawn
16 1 / 4
- Obtain a specimen for urine analysis
- Place the client on strict bedrest
Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.
- A client in active labor complains of cramps in her leg. What intervention should the
nurse implement?
- Ask the client if she takes a daily calcium tablet
- Extend the leg and dorsiflex the foot
- Lower the leg off the side of the bed
- Elevate the leg above the heart
- Extend the leg and dorsiflex the foot
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (B) and putting the heel of the foot on the floor is the best means of relieving leg cramps.
- The nurse is caring for a woman with a previously diagnosed heart disease who is in
the second stage of labor. Which assessment findings are of greatest concern?
- edema, basilar rales, and an irregular pulse
- Increased urinary output, and tachycardia
- Shortness of breath, bradycardia, and hypertension
- Regular heart rate, and hypertension
Edema, basilar rales, and an irregular pulse (A) indicate cardiac decompensation and require immediate intervention.
- The nurse is teaching a woman how to use her basal body temperature (BBT) pattern
as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and there for, the best time for intercourse to ensure conception?
- Between the time the temperature falls and rises
- Between 36 and 48 hours after the temperature rises
- When the temperature falls and remains low for 36 hours
- Within 72 hours before the temperature falls
In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception.
- A client who is in the second trimester of pregnancy tells the nurse that she wants to
use herbal therapy. Which response is best for the nurse to provide?
17 2 / 4
- Herbs are a corner stone of good health to include in your treatment
- Touch is also therapeutic in relieving discomfort and anxiety
- Your healthcare provider should direct treatment options for herbal therapy
- It is important that you want to take part in your care
The emphasis of alternative and complementary therapies, such as herbal therapy, is that the client is viewed as a whole being, capable of decision-making and an integral part of the health care team, so (D) recognizes the client's request.
- A mother who is breastfeeding her baby receives instructions from the nurse.
Which instruction is most effective to prevent nipple soreness?
- Wear a cotton bra
- Increase nursing time gradually
- Correctly place the infant on the breast
- Manually express a small amount of milk before nursing
The most common cause of nipple soreness is incorrect positioning (C) of the infant on the breast, e.g., grasping too little of the areola or grasping on the nipple.
- The nurse is counseling a woman who wants to become pregnant. The woman tells the
nurse that she has a 36-day menstrual cycle and the first day of her menstrual period was January *. The nurse correctly calculates that the woman's next fertile period is
- January 14-15
- January 22-23
- January 30-31
- February 6-7
This woman can expect her next period to begin 36 days from the first day of her last menstrual period - the cycle begins at the first day of the cycle and continues to the first day of the next cycle. Her next period would, therefore, begin on February 13. Ovulation occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this woman would occur January 31 (C).
- The nurse should encourage the laboring client to begin pushing when
- there is only an anterior or posterior lip of cervix left
- the client describes the need to have a bowel movement
- the cervix is completely dilated
- the cervix is completely effaced
Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated (A, B, and D), the cervix can become edematous and may never completely dilate, necessitating an operative delivery. Many primigravida’sctive laborbegin 100%a effaced and then proceed to dilate.
18 3 / 4
- 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 x 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
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription (D).
- A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The
nurse knows that the most likely presenting symptom for a pediatric client with AIDS is:
- shortness of breath
- joint pain
- a persistent cold
- organomegaly
Respiratory tract infections commonly occur in the pediatric population. However, the child with AIDS has a decreased ability to defend the body against these infections and often the presenting symptom of a child with AIDS is a persistent cold (C).
- A healthcare provider informs the charge nurse of a labor and delivery unit that a client
is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply)
- Dark, red vaginal bleeding
- Lower back pain
- Premature rupture of membranes
- Increased uterine irritability
- Bilateral pitting edema
- A rigid abdomen
The symptoms of abruptio placentae include dark red vaginal bleeding (A), increased uterine irritability (D), and a rigid abdomen (F).
- The nurse assesses a client admitted to the labor and delivery unit and obtains the
following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
19
- / 4