Maternity HESI Quizlet

HESI RN

1. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?

A. Administer oxygen by face mask.
B. Notify the healthcare provider of the client's symptoms.
C. Have the client breathe into her cupped hands.
D. Check the client's blood pressure and fetal heart rate.

Correct answer: C

Rationale: Tingling fingers and dizziness are symptoms of hyperventilation, which can occur with accelerated-blow breathing. Instructing the client to breathe into her cupped hands can help rebreathe exhaled carbon dioxide, which can alleviate the symptoms by restoring the proper balance of oxygen and carbon dioxide in the blood. This intervention can be effective in managing the client's hyperventilation without the need for additional medical interventions at this point.

2. During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

A. Observe the urethral opening on the surface of the penis when the newborn voids.
B. Perform transillumination of the scrotal sac to visualize shadows of the testes.
C. Use a fingertip to palpate the inguinal canal for a retractile or undescended testis.
D. Measure the size of the scrotal sac for length and width.

Correct answer: C

Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.

3. While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a 'V' shaped appearance. What action should the nurse take first?

A. Change the maternal position.
B. Administer oxygen at 10 L by mask.
C. Prepare for a potential cesarean.
D. Allow the client to begin pushing.

Correct answer: A

Rationale: In cases of fetal heart rate patterns showing abrupt falls and rises with a 'V' shaped appearance, it indicates possible cord compression. Changing the maternal position, such as moving the mother onto her side, can relieve the pressure off the cord and help improve fetal oxygenation, making it the priority intervention to address the decelerations.

4. At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

A. Check the hematocrit results.
B. Administer pain medication.
C. Increase the rate of IV fluids.
D. Monitor the client for contractions.

Correct answer: C

Rationale: The client's symptoms suggest hypovolemic shock, possibly due to an ectopic pregnancy. Increasing IV fluids is crucial to stabilize the client by improving blood pressure and perfusion. This intervention helps address the underlying issue of hypovolemia and supports the client's hemodynamic status, which takes priority in this emergent situation.

5. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?

A. Perform a gestational age assessment.
B. Obtain a drug screen for cocaine.
C. Determine reactivity of neonatal reflexes.
D. Weigh and measure the newborn.

Correct answer: B

Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.