HESI Maternity Test bank: Questions &
Answers.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage (Ans - A.Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn,
usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could not be detected by physical assessment alone.
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Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath (Ans - C.Allow the cord to air-dry as much as possible.
Rationale:Recent studies have indicated that air drying or plain water
application may be equal to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
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C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.(Ans - C.Place petroleum ointment around the glans with each diaper change and cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface.Prepackaged wipes often contain other products that may irritate the site.The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions.What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations 3 / 4
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth (Ans - C.Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug,
stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness. Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing.(Ans - C.Ensure that the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect
positioning of the infant on the breast for latching on. The baby's body is in
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