HESI RN
HESI Maternity 55 Questions Quizlet
1. What is the best nursing intervention for a pregnant woman with hyperemesis gravidarum?
- A. Administer prescribed IV solution.
- B. Give oral rehydration solution.
- C. Encourage small, frequent meals.
- D. Offer ginger tea to reduce nausea.
Correct answer: A
Rationale: The best nursing intervention for a pregnant woman with hyperemesis gravidarum is to administer the prescribed IV solution. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. Administering IV fluids helps in managing dehydration, replenishing electrolytes, and providing the necessary hydration for both the mother and the fetus. Giving oral rehydration solution (Choice B) may not be sufficient for severe cases of hyperemesis gravidarum where IV fluids are required. Encouraging small, frequent meals (Choice C) may not be effective as the woman may not be able to tolerate oral intake. Offering ginger tea (Choice D) is not the most appropriate intervention for hyperemesis gravidarum, as it may not provide adequate hydration or electrolyte balance needed in severe cases.
2. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The LPN/LVN knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as
- A. a cephalhematoma, caused by birth trauma and may last up to 8 weeks.
- B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications.
- C. molding, caused by pressure during labor and will disappear within 2 to 3 days.
- D. a subdural hematoma, which can result in lifelong damage.
Correct answer: A
Rationale: Cephalhematoma is the accumulation of blood between the periosteum and skull, often due to birth trauma, and typically resolves within weeks. It is a common finding in newborns and is not usually a cause for concern as it gradually resolves without specific treatment. Subarachnoid hematoma and subdural hematoma are different conditions that present with distinct characteristics and require different management strategies. Therefore, the correct answer is A. Subarachnoid hematoma is typically found in the subarachnoid space and requires immediate intervention, not just observation like cephalhematoma. Molding refers to the shaping of the fetal head during passage through the birth canal and is a temporary change, not a collection of blood like in cephalhematoma. Subdural hematoma is located beneath the dura mater and is associated with significant complications, unlike the self-limiting nature of cephalhematoma.
3. The healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?
- A. A gravida 6, para 5 who is 38 years of age and in early labor.
- B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
- C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
- D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.
Correct answer: D
Rationale: The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus. Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.
4. During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage?
- A. Insert a straight urinary catheter to drain the bladder.
- B. Scan the bladder for urinary retention.
- C. Palpate the suprapubic area for fetal head position.
- D. Test the fluid with a nitrazine strip.
Correct answer: D
Rationale: Testing the fluid with a nitrazine strip is the appropriate technique to differentiate between amniotic fluid and urine. This test helps in determining if the fluid leakage is amniotic fluid, which is crucial for guiding further management and ensuring appropriate care for the client during the third trimester of pregnancy. Inserting a straight urinary catheter to drain the bladder (Choice A) is unnecessary and invasive in this scenario as the concern is fluid leakage, not urinary retention. Scanning the bladder for urinary retention (Choice B) is also not indicated since the client reported fluid leakage, not retention. Palpating the suprapubic area for fetal head position (Choice C) is unrelated to assessing fluid leakage and not the appropriate technique in this situation.
5. The healthcare provider receives a newborn within the first minutes after vaginal delivery and intervenes to establish adequate respirations. What priority issue should the healthcare provider address to ensure the newborn's survival?
- A. Heat loss.
- B. Fluid balance.
- C. Bleeding tendencies.
- D. Hypoglycemia.
Correct answer: A
Rationale: Corrected Rationale: Immediately after birth, newborns are at high risk for heat loss, which can lead to cold stress and associated complications. Maintaining thermal regulation is crucial to prevent hypothermia and ensure the newborn's survival. By addressing heat loss as a priority issue, the healthcare provider can help stabilize the newborn's temperature and support overall well-being. Choices B, C, and D are not the priority issues immediately after birth. While fluid balance, bleeding tendencies, and hypoglycemia are important considerations in newborn care, heat loss is the primary concern right after delivery to prevent complications related to thermal regulation.
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