a breastfeeding infant screened for congenital hypothyroidism is found to have low levels of thyroxine t4 and high levels of thyroid stimulating hormo
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HESI RN

HESI Maternity 55 Questions Quizlet

1. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?

Correct answer: D

Rationale: High TSH and low T4 levels indicate that the thyroid gland is not producing enough hormones, which is a sign of congenital hypothyroidism. In this case, the high TSH is a compensatory response by the body to stimulate the thyroid to produce more T4. Choice A is incorrect because TSH does not directly affect T4 levels; rather, it is the other way around where low T4 levels lead to high TSH levels. Choice B is incorrect because high thyroxine levels are not expected in congenital hypothyroidism. Choice C is incorrect as the thyroid gland should be producing normal levels of thyroxine shortly after birth, making this explanation unlikely in the context of congenital hypothyroidism.

2. A client at 28 weeks gestation calls the antepartum clinic and reports experiencing a small amount of bright red vaginal bleeding without uterine contractions or abdominal pain. What instruction should the LPN/LVN provide?

Correct answer: A

Rationale: Bright red vaginal bleeding without pain could indicate placental issues such as previa. An ultrasound is necessary to evaluate the cause. It is important to rule out potential serious conditions like placental previa, which can lead to further complications for both the mother and the fetus. Therefore, prompt evaluation through an ultrasound at the clinic is essential for appropriate management and ensuring the well-being of the client and her baby.

3. Why is complete bedrest necessary for a pregnant client with mitral stenosis Class III?

Correct answer: A

Rationale: Complete bedrest is necessary for a pregnant client with mitral stenosis Class III to reduce the workload on the heart, lower oxygen consumption, and prevent complications associated with cardiac conditions like mitral stenosis. By remaining in bed, the client can help maintain cardiac function and promote a safer pregnancy outcome. Choice B is incorrect as it does not provide a specific reason related to the client's medical condition. Choice C is not addressing the medical necessity of bedrest for this particular client. Choice D is irrelevant and does not explain the importance of bedrest for a pregnant client with mitral stenosis Class III.

4. After breastfeeding for 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?

Correct answer: B

Rationale: After a newborn spits up breast milk following feeding, the priority action for the nurse is to sit the newborn upright and burp by rubbing or patting the upper back. This position helps release trapped air and reduces the likelihood of further spit-up or aspiration. It is essential to address this first to prevent potential complications and ensure the newborn's comfort and safety.

5. A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

Correct answer: C

Rationale: A decrease in respiratory rate from 24 to 16 indicates that magnesium sulfate is effectively reducing central nervous system irritability, a desired therapeutic effect. This decrease in respiratory rate signifies that the drug has reached a therapeutic level to control symptoms of severe pregnancy-induced hypertension. Choices A, B, and D are incorrect because 4+ reflexes, urinary output, and body temperature are not direct indicators of achieving a therapeutic level of magnesium sulfate for controlling PIH symptoms.

Similar Questions

At 40 weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home and is in active labor. The client feels the need to bear down and push. What information is most important for the nurse to obtain first?
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?
The nurse is caring for a client who experienced fetal demise at 32 weeks' gestation. After the fetus is delivered vaginally, the nurse implements fetal demise protocol and identification procedures. Which action is most important for the nurse to take?
Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8°F (35.8°C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and weak cry. Based on these findings, which action should the nurse implement?
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?

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