HESI RN
Maternity HESI Quizlet
1. A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks what is the purpose of the ointment. The nurse would be correct in stating that the purpose of the ointment is:
- A. Prevent eye infection.
- B. Dilate the pupil so the red reflex can be visualized.
- C. Clear the infant's vision.
- D. Prevent herpes infection.
Correct answer: A
Rationale: The correct answer is A: Prevent eye infection. Eye ointment, usually containing erythromycin, is applied to prevent neonatal conjunctivitis, which can be caused by bacteria present in the birth canal. It is not used to dilate the pupil, clear the infant's vision, or prevent herpes infection.
2. A neonate with congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?
- A. Discuss the need for cortisol and aldosterone replacement therapy after discharge
- B. Support the parents in their decision regarding the sex assignment of their child
- C. Offer information about ultrasonography and genotyping to determine sex assignment
- D. Explain that corrective surgical procedures consistent with sex assignment can be delayed
Correct answer: B
Rationale: Supporting the parents in their decision regarding the sex assignment of their child is crucial as it respects the parental role in making this important decision and helps provide emotional support during a challenging time. The primary focus should be on helping the parents navigate the complexities and implications of determining the sex assignment for their child with ambiguous genitalia.
3. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child’s plan of care?
- A. Allow the child to eat any food desired and tolerated.
- B. Provide small, frequent meals that are high in protein and calories.
- C. Offer the child preferred foods and avoid foods that are not well-tolerated.
- D. Consult with a dietitian to provide appropriate nutritional support.
Correct answer: B
Rationale: In children with leukemia undergoing chemotherapy, anorexia, nausea, and vomiting are common issues leading to altered nutrition. Providing small, frequent meals that are high in protein and calories is essential to address these symptoms and meet the child's nutritional needs effectively. This approach helps in managing the side effects of treatment and supporting the child's nutritional requirements during this challenging time.
4. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?
- A. Decrease the oxytocin infusion rate
- B. Determine current cervical dilation
- C. Request placement of the epidural
- D. Give a bolus of intravenous fluids
Correct answer: D
Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.
5. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan?
- A. Keep airway equipment at the bedside.
- B. Allow liberal family visitation.
- C. Monitor blood pressure, pulse, and respirations q4h.
- D. Assess temperature q1h.
Correct answer: A
Rationale: In a client with eclampsia, the priority intervention is to keep airway equipment at the bedside to manage potential convulsions effectively. This proactive measure is essential to ensure rapid response and intervention in case of convulsions, which can occur in clients with eclampsia.
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