which action should the nurse take if an infant who was born yesterday weighing 75 lbs 3402 grams weighs 7 lbs 3175 grams today
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HESI RN

Maternity HESI 2023 Quizlet

1. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

2. When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?

Correct answer: A

Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.

3. One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large, and her fundus is boggy despite massage. The client's pulse is 84 beats/minute, and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the healthcare provider take immediately?

Correct answer: D

Rationale: The correct action for the healthcare provider to take immediately is to call the healthcare provider to question the prescription. Methergine is contraindicated in clients with hypertension due to its potential to elevate blood pressure further. In this scenario, the client's blood pressure is already elevated at 156/96, making it unsafe to administer Methergine. The LPN/LVN should advocate for the client's safety by questioning the prescription to prevent potential harm.

4. At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

Correct answer: C

Rationale: The client's symptoms suggest hypovolemic shock, possibly due to an ectopic pregnancy. Increasing IV fluids is crucial to stabilize the client by improving blood pressure and perfusion. This intervention helps address the underlying issue of hypovolemia and supports the client's hemodynamic status, which takes priority in this emergent situation.

5. At 40-weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home, in active labor, and feeling the urge to push. What information should the nurse prioritize obtaining?

Correct answer: A

Rationale: Assessing the color and consistency of amniotic fluid is crucial as it can indicate the presence of meconium, which suggests potential fetal distress. This information guides the need for further assessments and interventions to ensure the well-being of the mother and fetus. Estimating the amount of fluid is not as critical as determining the color and consistency to identify fetal distress. While noting any odor is important, it is secondary to assessing the fluid itself. Knowing the time of membrane rupture is helpful but not as crucial as evaluating the characteristics of the amniotic fluid.

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