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HESI Maternal Questions N271 Exam With Complete Solutions., Exams of Nursing

HESI Maternal Questions N271 Exam With Complete Solutions.

Typology: Exams

2024/2025

Available from 07/06/2025

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HESI Maternal Questions N271 Exam With
Complete Solutions
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
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HESI Maternal Questions N271 Exam With

Complete Solutions

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

  • 19-21 inch (48-53 cm)
  • FOC 13-14 in (33-35 cm) The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What nursing action should be implemented? - answer Report findings to the healthcare provider. (Vasoconstriction of peripheral vessels, which can seriously impair circulation, is triggered by arterial vasospasm caused by the presence of the catheter.) A client at 35-weeks gestation visits the clinic for a prenatal check-up. Which complaint by the client warrants further assessment by the nurse? - answer Periodic abdominal pain. (Abdominal pain may indicate preterm labor or placental abnormalities.) A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and relatives. Which action should the nurse implement at this time? - answer Observe interactions of family members with the newborn and each other. Which gastrointestinal findings should the nurse be concerned about in a client at 28- weeks gestation? - answer Pica. (the consumption of low or non-nutrient substances , may cause more nutritious foods to be displaced from the diet, and depending on the substance ingested may be toxic or interfere with the absorption of nutrients and minerals.) Which cardiovascular findings should the nurse assess further in a client who is at 20- weeks gestation? - answer Decrease in pulse rate. (Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 bpm, which persists to term, so a decrease should be assessed further.) Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma? - answer Vitamin K (AquaMEPHYTON). (The normal neonate is Vitamin K deficient, so to rapidly elevate prothrombin levels and reduce the risk of

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.)