a client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit which nursing plan is best in assisting this mother
Logo

Nursing Elites

HESI RN

Maternity HESI Quizlet

1. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

Correct answer: D

Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.

2. A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?

Correct answer: C

Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective. Choices A, B, and D are incorrect because they do not directly reflect the expected outcome of epoetin alfa therapy. Increasing urinary output, changes in respiratory rate, and decreasing bilirubin levels are not primary indicators of the drug's effectiveness in this context.

3. 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.

4. A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

Correct answer: A

Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.

5. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?

Correct answer: B

Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.

Similar Questions

The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control which method should the nurse recommend to this client as best for her to use in preventing unwanted pregnancy?
The client is 24 weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?
What advice is most important for a client in the first trimester of pregnancy experiencing nausea?
A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother, who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which intervention is most important to implement?
After a full-term vaginal delivery, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses