HESI RN
HESI Maternity Test Bank
1. A client with no prenatal care arrives at the labor unit screaming, 'The baby is coming!' The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the LPN/LVN to obtain?
- A. Gravidity and parity.
- B. Time and amount of last oral intake.
- C. Date of last normal menstrual period.
- D. Frequency and intensity of contractions.
Correct answer: C
Rationale: Obtaining the date of the last normal menstrual period is crucial in estimating the gestational age of the fetus. This information helps in determining the progression of labor and the management of delivery. It also assists healthcare providers in assessing the overall health of the mother and the fetus. Choices A, B, and D are important in labor assessment, but in this scenario, the most crucial information needed is the date of the last normal menstrual period to estimate the gestational age.
2. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
- A. Muscle tension decreases with fine motor skill projects, so these activities should be encouraged.
- B. The chorea or movements are temporary and will eventually disappear.
- C. Permanent lifestyle changes are not needed to promote safety in the home.
- D. Consistent discipline is not directly related to controlling the movements.
Correct answer: B
Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course. Choices A, C, and D are incorrect because muscle tension, permanent lifestyle changes, and consistent discipline are not directly related to the resolution of chorea in rheumatic fever.
3. After a client delivered vaginally 2 days ago, what information should you share with her if she wants to resume using her diaphragm for birth control?
- A. The diaphragm is the most effective form of contraception.
- B. The diaphragm must be refitted after childbirth.
- C. Vaseline lubricant should be used when inserting the diaphragm.
- D. The diaphragm should be inserted 2 to 4 hours before intercourse.
Correct answer: B
Rationale: After childbirth, the diaphragm must be refitted to ensure a proper fit and effectiveness. Changes in the body post-delivery can affect the fit of the diaphragm, making it necessary to get refitted. Choice A is incorrect because while the diaphragm can be effective, it is not the most effective form of contraception. Choice C is incorrect because oil-based lubricants like Vaseline can damage latex diaphragms. Choice D is incorrect because the diaphragm should be inserted no more than 2 hours before intercourse, not 2 to 4 hours.
4. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
- A. 3+ deep tendon reflexes and hyperreflexia.
- B. Periorbital edema, flashing lights, and aura.
- C. Epigastric pain in the third trimester.
- D. Recent decreased urinary output.
Correct answer: A
Rationale: In a client with preeclampsia, 3+ deep tendon reflexes and hyperreflexia are indicative of severe preeclampsia. These neurological signs suggest an increased risk for seizures, making option A the most indicative of an impending convulsion. Choices B, C, and D are not directly associated with an impending convulsion in a client with preeclampsia.
5. At 40-weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home, in active labor, and feeling the urge to push. What information should the nurse prioritize obtaining?
- A. Color and consistency of fluid.
- B. Estimated amount of fluid.
- C. Any odor noted at the rupture of membranes.
- D. Time of membrane rupture.
Correct answer: A
Rationale: Assessing the color and consistency of amniotic fluid is crucial as it can indicate the presence of meconium, which suggests potential fetal distress. This information guides the need for further assessments and interventions to ensure the well-being of the mother and fetus. Estimating the amount of fluid is not as critical as determining the color and consistency to identify fetal distress. While noting any odor is important, it is secondary to assessing the fluid itself. Knowing the time of membrane rupture is helpful but not as crucial as evaluating the characteristics of the amniotic fluid.
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