after each feeding a 3 day old newborn is spitting up large amounts of enfamil newborn formula a nonfat cows milk formula the pediatric healthcare pro
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Nursing Elites

HESI RN

Maternity HESI 2023 Quizlet

1. After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate-based infant formula. What information should the LPN/LVN provide to the mother about the newly prescribed formula?

Correct answer: D

Rationale: The LPN/LVN should inform the mother that Similac® Soy Isomil® Formula is a soy-based formula containing sucrose. This formula is suitable for infants with cow's milk protein allergy or intolerance, which may be the reason for the newborn spitting up large amounts of the previous cow's milk formula.

2. 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?

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.

3. What is the most important assessment for the healthcare provider to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Correct answer: A

Rationale: Following the administration of epidural anesthesia, the most crucial assessment for the healthcare provider to conduct is monitoring maternal blood pressure. Epidural anesthesia can lead to hypotension as a common side effect, which can have significant implications for both the mother and the fetus. Therefore, close monitoring of maternal blood pressure is essential to detect and manage any hypotensive episodes promptly. Choices B, C, and D are important assessments during labor and delivery, but in this specific scenario of post-epidural anesthesia, monitoring maternal blood pressure takes precedence due to the potential risk of hypotension.

4. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?

Correct answer: A

Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.

5. Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Correct answer: C

Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.

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