HESI RN
Maternity HESI Quizlet
1. An off-duty healthcare professional finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
- A. Use a sterile item to tie off the umbilical cord.
- B. Provide privacy for the woman.
- C. Reassure the husband and try to keep him calm.
- D. Put the newborn to breast.
Correct answer: D
Rationale: Putting the newborn to breast is the highest priority intervention in this scenario. It helps stimulate uterine contractions in the mother, which aids in controlling postpartum bleeding. Additionally, placing the newborn to breast promotes bonding between the mother and infant, provides comfort to the baby, and facilitates the initiation of breastfeeding. Ensuring the well-being of both the mother and the newborn is essential in this critical situation.
2. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?
- A. Alert the neonatal team and prepare for neonatal resuscitation
- B. Notify the healthcare provider from the client’s bedside
- C. Obtain written consent for an emergency cesarean section
- D. Draw a blood sample for stat hemoglobin and hematocrit
Correct answer: B
Rationale: In this scenario, the priority action for the nurse is to notify the healthcare provider from the client's bedside. The clinical presentation of severe abdominal pain, bright red vaginal bleeding, rigid and tender abdomen, along with fetal bradycardia (FHR 90 bpm) and maternal tachycardia (120 bpm) indicates an urgent need for medical intervention. Notifying the healthcare provider promptly allows for immediate assessment and decision-making to address the critical condition and ensure timely and appropriate management for both the mother and fetus.
3. In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?
- A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
- B. Growth and development have been abnormal since birth.
- C. Muscular strength can be regained with physical exercise and therapy.
- D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.
Correct answer: A
Rationale: In Duchenne muscular dystrophy, a key characteristic is the progressive weakness in the lower legs, leading to a waddling, unsteady gait. The nurse should focus on teaching about this aspect as it helps in understanding the disease's progression and managing the symptoms effectively.
4. During a non-stress test (NST) at 41-weeks gestation, the LPN/LVN notes that the client is not experiencing contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are present. What action should the nurse take?
- A. Check the client for urinary bladder distention.
- B. Notify the healthcare provider of the nonreactive results.
- C. Have the mother stimulate the fetus to move.
- D. Ask the client if she has felt any fetal movement.
Correct answer: D
Rationale: In this scenario, the nurse should ask the client if she has felt any fetal movement. This action is important as assessing for fetal movement can help determine if the absence of FHR accelerations is attributed to fetal sleep or decreased fetal activity. It is crucial to gather information directly from the client to aid in the assessment and decision-making process. This approach can provide valuable insights into the fetal well-being and guide further interventions if needed.
5. 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 the client's nursing care plan?
- A. Assess temperature every hour.
- B. Allow liberal family visitation.
- C. Monitor blood pressure, pulse, and respirations every 4 hours.
- D. Keep an airway at the bedside.
Correct answer: D
Rationale: In the case of eclampsia, the priority intervention is to keep an airway at the bedside. Eclampsia is associated with a high risk of convulsions, and having an airway readily available is crucial for prompt intervention in the event of seizures. Assessing temperature, allowing family visitation, and monitoring vital signs are important aspects of care but ensuring airway patency takes precedence in this situation to manage potential complications and ensure the client's safety.
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