a multiparous client is involuntarily pushing while being wheeled into the labor triage area the nurse observes the fetal head presenting at the perin
Logo

Nursing Elites

HESI RN

Maternity HESI Quizlet

1. A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?

Correct answer: A

Rationale: When the fetal head is visible at the perineum, the priority is to support the infant's birth to prevent injury. Providing support as the infant emerges helps ensure a safe delivery process and reduces the risk of complications associated with rapid or uncontrolled birth.

2. The client is 24 weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

Correct answer: C

Rationale: An abnormal oral glucose tolerance test result is indicative of gestational diabetes. This test is crucial in diagnosing gestational diabetes as it evaluates how well the body processes glucose after a sugary drink. Reporting abnormal results promptly allows for timely intervention and management to ensure the well-being of both the mother and the baby. The other options are not the primary tests used to diagnose gestational diabetes. Hemoglobin A1C is not recommended for diagnosing gestational diabetes as it reflects long-term glucose control. Postprandial blood glucose and fasting blood glucose tests are not as sensitive as the oral glucose tolerance test for diagnosing gestational diabetes.

3. In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the

Correct answer: D

Rationale: The anterior fontanel typically closes between 12 to 18 months, while the posterior fontanel usually closes by the end of the second month. It is important for parents to know these timeframes as it helps in monitoring the normal growth and development of their newborn. Delayed closure of fontanels may indicate potential health issues, and early closure may also warrant further evaluation by healthcare providers.

4. A client who is receiving oxytocin to augment early labor begins to experience tachysystolic tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?

Correct answer: A

Rationale: When a client experiences tachysystolic tetanic contractions with variable fetal heart decelerations, indicating uterine hyperstimulation, the priority action is to turn off the oxytocin infusion. This step aims to reduce uterine activity, which can compromise fetal oxygenation and lead to adverse outcomes.

5. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

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.

Similar Questions

A child with ADHD needs help with homework. What should the nurse encourage the parents to do?
The healthcare provider is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
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?
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?
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the LPN/LVN to assess the client for which condition?

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