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HESI Maternal Questions N271 Exam With Complete Solutions.
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A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? - answer Document the finding in the infant's record. Which assessment finding should the nursery nurse report to the pediatric healthcare provider? - answer Central cyanosis when crying. At 14 weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the RLQ of the abd. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abd pain and a shoulder pain. Assessment findings including diaphoresis, a HR of 120 bpm, and a BP of 86/48. Which action should the nurse implement next? - answer Increase the rate of IV fluids. An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screening for someone to help his wife. What intervention has the highest priority? - answer Put the newborn to breast. The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important to assess the client for which condition? - answer Gestational diabetes. A full term infant is transferred to the nursery from L & D. Which information is most important for the nurse to receive while planning care for the newborn? - answer Infant's condition at birth and treatment received. A client who is in the second trimester of pregnancy tells the nurse she wants to use herbal therapy. Which response is best for the nurse to provide? - answer It is important you want to take part in your care. The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? - answer Lubricant, a sterile glove, and an anmnihook. The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the
nurse determines that the neonate has a maturity rating of 40 weeks. What findings should be nurse identify to determine if the neonate is small for gestational age? - answer Admission weight of 4 lbs, 15 oz (2244 grams) Head to heel length of 17 inches (42.5 cm) Frontal occipital circumference of 12.5 inches (31.25 cm) When providing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term? - answer Vernix is a white, cheesy substance, predominantly located in the skin folds. Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of gravid client? - answer Client's readiness to learn The nurse identifies crepitus when examining the chest of a newborn client who was delivered vaginally. Which further assessment should the nurse perform? - answer Observe for an asymmetrical Moro (startle) reflex The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? - answer Advise the client to breathe into her cupped hands. An expectant father tells the nurse he fears that his wife is losing her mind. He states that she is constantly rubbing her abdomen and talking to the baby, and that she reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? - answer Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement. Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? - answer Her arms and hands receive the infant and she then traces the infant's profile w/ her fingertips. A primigravida at 40 weeks gestation is receiving oxytocin to augment labor. Which adverse effect should the nurse monitor for during Pitocin? - answer Hyperstimulation. A client at 32 weeks gestation is hospitalized with severe pregnancy induced hypertension (PIH) and MgSo4 Is prescribed to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? - answer A decrease in RR from 24 to 16.
labor as well as prolong the progress of labor. A client is experiencing "back" labor and complains of intense pain in the lower lumbar- sacral area. What action should the nurse implement? - answer Apply counter pressure against the sacrum. The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand? - answer Report uterine cramping or low backache. When assessing a newborn infant's heart rate, which technique is most important for the nurse to take? - answer Count the heart rate for at least one full minute. A woman who is bottle-feeding her newborn infant calls the clinic 24 hours after delivery and tells the nurse that both of her breasts are swollen, warm and tender. What instructions should the nurse give? - answer Apply ice to the breasts. The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? - answer Give 10 L of oxygen via face mask. (Late decelerations occur when there is reduced placental and fetal perfusion. Administering O increases the O2 sat in the blood thus increasing O2 in the fetus.) What nursing action should be implemented when intermittently gavage-feeding a preterm infant? - answer Allow formula to flow by gravity. The normal, full-term, appropriate for gestational age (AGA) newborn should be/have - answer • 2700-4000 g in weight
abdominal US.) When discussing birth in a home setting with a group of women, which situation should nurse include about the safety of a home birth? - answer Medical backup should be available quickly in case of complications.. (Access to quick emergency care should be available in the event that an unforeseen complication arises during a home birth.)