HESI RN Maternity Assignment Exam
At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention?-uterine cramping -abdominal tenderness -systolic bp <100 mmHg -intermittent nausea (Ans- A. Uterine cramping
A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client?-the client may have a bladder or kidney infection -bladder capacity increases during pregnancy -during pregnancy a woman is especially sensitive to body functions -the growing uterus is putting pressure on the bladder (Ans- D. The growing uterus is putting pressure on the bladder.
The nurse assesses a male newborn and determines that he has the
following vital signs: axillary temperature 95.1 F, heart rate 136
beats/minute, and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first?-check the infant's ABGs 1 / 4
-notify the pediatrician of the infants VS -assess the infant's blood glucose level -encourage the infant to take the breast or sugar water (Ans- C. Assess the infant's blood glucose level
An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%.What is the priority nursing intervention?-evaluate the blood pH -begin humidified oxygen via hood -stimulate infant crying -place the infant under a radiant warmer (Ans- B. Begin humidified oxygen via hood
When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?-quiet the infant before counting the HR -listen at the apex of the heart -count the HR for at least one full minute -palpate the umbilical cord (Ans- C. Count the heart rate for at least one full minute
The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make?-inform the mother that the injection was prescribed by the HCP -explore the mother's concerns about the infant receiving an injection of vitamin K 2 / 4
-explain that vitamin K is required by state law and compliance is mandatory -remind the mother that all babies receive this shot and it is relatively painless (Ans- B. Explore the mother's concerns about the infant receiving an injection of vitamin K
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?-avoid alcohol bc it is excreted in breast milk -avoid spicy foods to prevent infant colic -increase caloric intake by approx. 500 calories/day -double prenatal milk intake to improve vitamin D transfer to the infant (Ans- A. Avoid alcohol because it is excreted in breast milk
Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor?-brighten the lighting so the mother can view the infant -complete the newborn assessment as quickly as possible -provide positive reinforcement for maternal care of infant -encourage early initiation of breast or formula feeding (Ans- D. Encourage early initiation of breast of formula feeding
A client at 8-weeks gestation asks the nurse about the risk fora congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur?-it depends on what the causative factors are for a CHD 3 / 4
-we don't really know what or when CHDs occur -they usually occur in the first trimester of pregnancy -the heart develops in the third to fifth weeks after conception (Ans- D. The heart develops in the third to fifth weeks after conception
A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide?-many women imagine what their baby is like by interpreting fetal movements -the fetus in utero is capable of hearing and does respond to the mothers voice -the HCP should address her concerns about her baby hearing function -the interaction b/w the mothers voice and the fetus's response ensures bonding (Ans- B. The fetus in utero is capable of hearing and does respond to the mother's voice
A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide?-this is a demonstration of the fetus acoustical reflux -the fetus can respond to sound by 24 weeks -it is a coincidence the fetus responded at the same time -report behavior to HCP (Ans- B. The fetus can respond to sound by 24-weeks gestation
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